An Integrated Substance Abuse Treatment
Needs Assessment for North Dakota

Final Report

Prepared by
William McAuliffe, Ph.D.
Ryan P. Dunn, B.A.
Caroline Zhang, M.A.

North Charles Research and Planning Group
North Charles, Inc.
875 Massachusetts Avenue
Cambridge, MA 02139
September 2, 2002
Phone: (617) 864-9115
wmcauliffe@ntc.org

North Dakota Department of Human Services (NDDHS)
Carol K. Olson, Executive Director
Division of Mental Health and Substance Abuse Services (DMHSAS)
Karen Romig Larson
600 South Second Street, Suite 1E
Bismark, ND 58504
Phone: (701) 328-8921
Toll Free: (800) 755-2719
TTY: (710) 328-8969
dhsmhsas@nd.gov

CSAT CONTRACT # 270-98-7064

Acknowledgements

The authors wish to acknowledge the contributions of others that made this study possible. The Center for Substance Abuse Treatment (CSAT) provided funding, administrative, and technical support for this study. Debra Fulcher was the CSAT project officer. Without CSAT's support for the State Treatment Needs Assessment Program (STNAP) this study and the studies upon which it drew would not have been possible. The entire field has advanced greatly as a result of the STNAP initiative.

The study's North Dakota project officer, Sue Tohm, helped out in more ways than we can mention here and showed great patience as the authors worked on the study. Karen Larson and Lauren Sauer of the Division of Mental Health and Substance Abuse Services offered indispensable insights on the treatment system. Kerry Wicks of the State Hospital generously shared his knowledge of the treatment needs of the homeless. Al Lick of the Department of Juvenile Services enthusiastically provided information on the juvenile corrections population and their treatment needs. Mike Froemke lent his knowledge of the needs of prisoners and their treatment system. Girish Budhwar was closely involved in implementation of the social indicator model.

The Gallup Organization conducted the telephone survey that was critical to completion of this integrated study. Many former North Charles staffers worked on the assessment of the treatment needs of recently incarcerated prisoners and the homeless, and the social indicator study; they included Richard LaBrie, Eric Sevigny, Ryan Woodworth, Jamie Mellitt, Stephen Haddad and Timothy Stablein. Athena Kazantzas provided administrative support while the Integration Study was being conducted. Earlier work by Stephanie Geller of the National Technical Center for Substance Abuse Needs Assessment created the foundation for the integrated analysis. Gary Houle, North Charles's Executive Director, has assisted in numerous ways over the years.

Authors

William E. McAuliffe is an associate professor in the Department of Psychiatry, Harvard Medical School at Cambridge Hospital. He has been a professor at Harvard since he received his doctorate in sociology from the Johns Hopkins University in 1972. His research has focused on drug abuse research, quality of medical care, and services planning. One of his studies earned him the Socio-Psychological Prize awarded by the American Association for the Advancement of Science in 1974. He developed a relapse prevention program for heroin and cocaine addiction, which is described in Recovery Training and Self Help: Relapse Prevention and Aftercare for Drug Addicts (Rockville, MD: National Institute on Drug Abuse, 1993). Dr. McAuliffe is Director of the National Technical Center for Substance Abuse Needs Assessment and the North Charles Research and Planning Group.

Caroline (Hui) Zhang is a Research Associate/Programmer at North Charles Research and Planning Group. She received her master's degree in economics from Tufts University in 2001. Before joining North Charles , she was a Research Assistant at Tufts where she worked on the Chinese Household Health & Nutrition Survey analysis and the Tobacco Use Survey analysis.

Ryan Dunn is a research assistant at North Charles Research and Planning Group. He received his bachelor's degree in economics from Vassar College in 2001.

Table of Contents

Executive Summary

• Introduction
• Methods
• National Trends
• Interstate Comparisons
• Households With Telephones
• Households Without Telephones
• American Indians
• Prisoners
• Homeless
• Gap Analysis
• Intrastate Variations
• Levels of Care, Obstacles, and Desired Treatment
• Summary and Conclusions

Executive Summary

This final report describes the integrated results of a family of studies of the substance use disorder treatment needs of North Dakota's citizens, especially those who are most in need of services. Employing funds from the Center for Substance Abuse Treatment (CSAT), State officials contracted with the National Technical Center (NTC) of the North Charles Research and Planning Group (NCRPG) to conduct this study. The problems and issues that were addressed included the answers to three basic planning questions:

• How many people are in need of treatment in the State? The goal was to have an adequate supply of services to meet the absolute level of demand that these cases would produce.
• Where should services be located? The goal was to locate where services are needed most.
• What mix of treatment modalities do these clients need and want? The goal is to match additional treatment services to the needs and desires of those who need and want them in order to achieve maximal effectiveness and efficiency.

North Dakota's Needs Assessment Studies

North Dakota conducted two rounds of needs assessment studies. The first round of studies included a household telephone survey, a survey of American Indians on reservations, an integrated study, and a social indicator study. The second round of studies included a social indicator study and the present integrated needs assessment.

Integrated Analysis

The integrated analysis presented in this report employed a series of methodologies to estimate the overall level of treatment needs in the State. First, the study examined trends in the past decade with regard to the need for treatment and the supply of services nationwide. Second, the study compared the State with other states to assess the comparative level of needs and services. Third, the analysis developed estimates of the past-year treatment needs of components of the State's population. The study integrated estimates of treatment need and services received for residents aged 12 and older of households with and without telephones, the homeless, and recently incarcerated prisoners. The sum of these estimates was a statewide estimate of the number of people who had a substance use disorder in the past year, how many of them have not received treatment, and how many would seek treatment if it were readily available. Analysis of the survey data assessed the levels of care needed to fill unmet demand and obstacles preventing those in need from obtaining treatment. Finally, the analysis used the State's social indicator data to determine where additional services were needed most.

National Trends. Analysis of a series of indicators of need and treatment services revealed that over the past decade the gap between the number of people in need and the amount of treatment services provided to them appeared to have been widening. Indicator trends were somewhat mixed. While alcohol use, alcohol mortality, DUI arrests, and alcohol treatment clients and admissions have declined, survey estimates of alcohol dependence and liquor law violation arrests have increased in the last decade. Some drug need indicators (e.g., positive drug tests among employees) suggested a long-term decline, other indicators (e.g., drug dependence rates, treatment measures) have been mixed or relatively stable, while yet other indicators (e.g., mortality, emergency room episodes, arrests, and survey reports of use) suggested increases, especially among young people, in the second half of the last decade. Cocaine use has declined, but use of stimulants and club drugs (e.g., Ecstasy) has increased.

To measure the relative gaps between the measures of treatment need and services, the authors divided the service rates by need indicators. Regardless of which measures of need (dependence, mortality or arrests) or services (survey, UFDS or TEDS) were considered, the gap between alcohol need and treatment increased over the decade of the 1990s. The alcohol treatment gap appeared to widen because there was a sharper decline in the number of persons receiving treatment than in the indicators of need that declined, and some of the indicators of need increased. Depending on which drug need and service indicators were used, the analysis suggested that the drug treatment gap widened or at least stabilized. Thus, over the past decade the amount of treatment per need for drugs and alcohol combined decreased.

Interstate Comparisons. To measure the adequacy of the State's treatment services relative to other states, the authors created a series of composite treatment need indexes. The Drug Need Index (DNI) consisted of the sum of standardized mean rates per 100,000 of explicit-mention drug mortality and drug possession/sale arrests. Similarly structured, the Alcohol Need Index (ANI) consisted of the sum of explicit-mention alcohol mortality rates and arrests rates for driving under the influence (DUI) and liquor law violations. The Substance Need Index (SNI) combined standardized explicit-mention drug and alcohol mortality rates and the sum of the drug and alcohol arrest rates.

North Dakota's biggest substance use problem is alcoholism. Its alcohol treatment need as measured by the ANI (55) ranked 14^th highest in the country in 1994-1996 . North Dakota's alcohol mortality rate was the 18^th highest in the country, and its alcohol arrest rate ranked 13^th highest. North Dakota ranked 3^rd on the BRFSS's measure of driving after drinking too much, and 23 ^rd on the alcohol-related traffic fatality rate . The State's alcohol treatment services were ranked slightly lower than one would expect based on the need indicators . That is, while the State's alcohol treatment needs were in the second highest quintile in the country according to the index, its treatment services were in the middle quintile according to the UFDS alcohol-only treatment client rate.

North Dakota's controlled drug treatment needs were the lowest in the nation. The State's DNI score of 9 was half that of the next lowest score (West Virginia and Vermont both scored 18) , but North Dakota ranked 35^th in the nation according to the NHSDA's 1999 household survey estimates of drug dependence. Unlike the DNI, the NHSDA's dependence measure consists mostly of cases of marijuana dependence. Consistent with North Dakota's NHSDA dependence measure, North Dakota had the highest percentages of marijuana arrests and marijuana treatment admissions. Compared to other states, North Dakota had the lowest drug mortality mean rate between 1994 and 1996 (0.31 per 100,000) and the second lowest mean drug arrest rate between 1994 and 1996 (119 per 100,000) . North Dakota had the lowest rate of drug-only treatment clients (15 per 100,000) in the UFDS between 1994 and 1996 and the second lowest rate of primary drug admissions (47 per 100,000) among the 41 states that reported to TEDS. The State's low treatment rate matches its low level of need for drug treatment.

North Dakota's Substance Abuse Need Index (SNI) ranking was 24 ^th in the country, clearly attributable to its high level of alcohol treatment needs. The State's combined UFDS substance abuse client rate (alcohol-only, drug-only, and drug plus alcohol) ranked 32 ^nd in the country for 1994-1996. By this measure, North Dakota's treatment services were again one quintile below its moderate overall treatment needs.

Trends in North Dakota. North Dakota's alcohol arrest (DUI, disorderly conduct, and liquor law violations) rates and explicit-mention alcohol mortality rates increased from 1993 to 1998. The other alcohol need indicators were stable over that period. Alcohol treatment admissions (TEDS data) declined slightly over the years between 1994 to 1998. It appears that the rate of admissions compared to rates of arrests and deaths, a proxy for the proportion in need who received treatment, has decreased slightly over time, suggesting a widening of the treatment gap. Whereas the alcohol indicators increased only slightly, the controlled drug indicators in North Dakota increased more sharply during the period from 1993 to 1998 . While drug admissions and drug clients increased as well, the increases in drug mortality and arrests appeared to be sharper. These trends suggest a widening of the drug treatment gap.

Statewide Treatment Need Estimate. To estimate the absolute number of persons in North Dakota who had a past-year substance use disorder, the study combined prevalence and population estimates of treatment need for adults (18 and over) in households with telephones, adolescents in households with telephones, persons 12 and older living in households without telephones, recently incarcerated state prisoners and training school inmates, and homeless people. Applying these estimates to population statistics from the 2000 Census count resulted in an estimated total of 30,880 people with a substance use disorder in North Dakota during the past year.

Whenever possible, the authors made conservative assumptions. It would be reasonable therefore to assume that there were at least 30,880 people with current substance use disorders in the State. If these individuals sought treatment, they would meet the minimum medical necessity criteria employed by treatment programs and managed care organizations.

Although residents of households with telephones account for the largest proportion of cases in the total, generalizing the prevalence rate for that group (5.2%) to the rest of the population would have produced an underestimate of the total number of people in need. In its report of the household survey, the Gallup Organization (1998) applied the telephone survey estimate to the entire population aged 18 and older rather than just the population of adults in households with telephones. After the present authors took the prevalence estimates for the other groups, the estimated total state prevalence rate for persons 12 and older increased to 5.9%. Each of the population subgroups not covered by the telephone survey (residents of households without telephones, recently incarcerated prisoners, and homeless, adolescents in households with telephones, and training school inmates) had a higher estimated prevalence of substance use disorders than the adults in households with telephones (11.1%, 62.5%, 47%, 8.5%, and 62.5% respectively). Although the prisoners and homeless had the highest estimated prevalence rates, they were small populations and therefore contributed relatively few cases to the total population in need. Persons 12 and older in households without telephones had a prevalence rate that was a little more than twice as high the prevalence rate of the adults in households with telephones. Because adolescents in households with telephones was a relatively large subpopulation, they contributed the most (4,820 cases or 15.6%) to the overall increase in the estimate of the total need for treatment. By estimating the rates for the groups other than those covered by the telephone survey rather than generalizing the prevalence rate from the telephone survey, the present integrated analysis arrived at an estimated number of people in need that was higher by 3,707 people.

Treatment Gap. There were clearly many people in North Dakota with a substance use disorder who did not obtain treatment in the past year. In 2000, an estimated 2,826 North Dakota residents received treatment for a substance use disorder. This number equals 9.2% of the estimated 30,880 people in need of treatment that year. These figures are probably the most reliable measure of the treatment gap in North Dakota.

Unmet Demand for Treatment. Even if treatment were readily available to all who needed it, only a portion of those in need would seek care in a given year. The study's surveys asked respondents who had a substance use disorder but who had not obtained treatment whether they thought they needed treatment and would have sought it had it been readily available. The integrated analysis estimated that 4.3% of the persons with a current disorder that did not obtain treatment in the past year said they thought they needed treatment and would have sought it if it were more readily available. Compared to several other states, that percentage was relatively low. Applied to the state's population, the study estimated that 1,204 North Dakota residents needed and wanted treatment in the past year but did not obtain it. This number would be a reasonable target for providing additional services, if the State sought to provide treatment on demand. Experience in other states suggests that survey estimates of unmet demand have successfully predicted the utilization of new substance abuse treatment services. This success appeared to depend on the type of treatment and location of the services in areas that clearly had relatively high levels of unmet need. If the State increased the number of people in need who obtained treatment by 1,204, the number who received treatment would increase by 43%. The total number who would receive care (4,030) would be 13.1% of the 30,880 who needed it.

Analysis of the telephone survey data showed that about one in five of the subjects who needed treatment and had not obtained it but wanted it should receive residential or hospital care in accordance with the patient placement criteria of the American Society for Addiction Medicine (ASAM). The remaining subjects should receive intensive outpatient treatment.

When asked what prevented them from obtaining treatment, North Dakota telephone survey respondents were most likely to cite lack of insurance, facilities being located too far away, programs being full, and lack of ancillary services such as child care or medical care.

Location of Treatment Needs

The authors compared the average annual treatment admissions rate for 1994-1998 (State data) with the SNI to determine how well the observed regional treatment admissions rates compared to the rates predicted by the Substance Abuse Need Index. In general, the existing distribution of treatment resources in North Dakota reflects relative need among regions reasonably well. Forty-seven percent of the variation in client rates among regions was explained by the SNI scores. Region V, the most populous region in North Dakota, had the largest gap (the observed average annual admissions minus the average admissions expected on the basis of need).

To allocate services geographically to meet the needs of the 1,204 persons with unmet demand, the authors used the SNI to ensure that all regions would have a treatment service rate consistent with its level of need . Because the current regional admissions rates already matched need reasonably well and because serving 1,204 more persons represents a substantial increase in the number of people served statewide, the analysis allocated some additional services to all regions.

The authors recommend that the State consider using the results of this analysis as one part of its decision making process for allocating services if additional funds become available. Although the authors found that the indicator data at the regional level to were reliable and valid, no single measure should be relied on in isolation. Accordingly, the estimates should be used along with other qualitative and quantitative information (e.g., knowledge of waiting lists in specific areas or concerns by other medical personnel or social agencies regarding the availability of specific services). Responses of local providers to the reasonableness of the estimates should also be considered. The social indicator methodology has been developed over a period of years, and has been used in other states. Whenever it is employed in a new state for the first time, there is always the possibility that modification must be made to refine the indexes.

Conclusions

The results of the needs assessment suggest that North Dakota would be justified in expanding its treatment services. The analysis of national, interstate, longitudinal data, and crossectional survey data produced evidence that a substantial number of the State's residents had an active addictive disease in the past year, but only a small percentage of them received treatment in the past year. While many of those individuals would probably not seek treatment immediately if the supply of services were increased, an estimated 1,204 people indicated that they wanted treatment even though they did not obtain it. Only experience will show how many of even that group will seek care, but the number is sufficiently large to suggest that an increase in the number of facilities would be reasonable. Recent statistics suggested that the treatment gap, especially regarding drugs, has been widening, and a reversal of that trend appears to be in order.

The analysis suggested that the State may wish to consider programming (e.g., outreach) directed towards increasing the proportion of persons in need who actually seek treatment. The persons who said that they wanted treatment was relatively small, and this group, especially in high-risk groups such as prisoners-to-be and homeless people, appeared to need relatively high levels of care, mostly residential and hospital treatment at the onset of treatment. Many of the household residents who wanted treatment appear to need intensive outpatient treatment to initiate treatment. Research suggests that location of future services in accordance with the indicators of unmet need, especially in rural areas, may be a key step for increasing the demand for treatment. Several administrative changes, such as reducing red tape, could make a difference. To increase access to treatment in rural areas, especially for youth, the State may wish to investigate the feasibility and efficacy of online counseling, assessment, and referral. Analysis of survey data from other states indicated that adolescents obtain a large proportion of treatment services from nonspecialty providers (e.g., clergy, school health counselors, general psychological counselors, and social workers). An important consideration for youth and residents of small towns and rural areas is the stigma attached to obtaining treatment services from specialty providers. A recent report by the National Center for Addiction and Substance Abuse suggests that relatively few of some nonspecialty providers such as clergy have received substance abuse training. Of course, attention to cultural issues and identification is important for American Indians.

The integrated analysis indicated several areas for which additional needs assessment research should be considered. The need indexes developed for the study should be kept up to date and refined. A commitment to ongoing data collection and updating of the social indicator data each year could provide the State with timely data for future planning. The study had to estimate the treatment needs of homeless and adolescents from studies conducted in other states. Those are two groups the state may consider studying in future rounds of the State Treatment Needs Assessment Program.

Introduction

This final report describes the integrated results of a family of studies of the substance use disorder treatment needs of North Dakota's citizens, especially those who are most in need of services. Employing funds from the Center for Substance Abuse Treatment (CSAT), State officials contracted with the National Technical Center (NTC) of the North Charles Research and Planning Group (NCRPG) to conduct this study.

Purpose of the Study

A primary objective of the study was to provide the State with the data it needs for its planning process. To assist the State in obtaining essential needs assessment data in a form that is most useful for the planning process, the integrated analysis made use of the needs assessment and resource data collected by the State in two rounds of needs assessment studies. The analysis can serve as a model for a systematic assessment of the adequacy of the current population treatment needs and services.

Problems and Issues

When conducting the comprehensive needs assessment for treatment of substance abuse, the authors sought to answer three basic planning questions:

• a. How many people were in need of treatment in the State during the past year? The goal was to have an adequate supply of services to meet the absolute level of demand that these cases would produce.
• b. Where should services be located? The goal is to locate the services where they are needed most.
• c. What mix of treatment modalities do these clients need and want? The goal is to have the optimal mix of treatment services to achieve maximal effectiveness and efficiency.

The study team examined data on treatment needs. It compared those needs with current resources in amount, type and location. It also examined special service delivery issues, such as the barriers to treatment service delivery in the large rural areas of the State and the service needs of such special populations such as women, American Indians, prisoners, and the homeless. The analysis used this information as a basis for recommendations regarding the gaps between treatment need and utilization.

Background

The roots of this comprehensive population-based study can be found in the recommendations of the Institute of Medicine's landmark study, Treating Drug Problems (Gerstein and Harwood 1990). The study recommended that each state conduct studies that produce objective estimates of need and use the resulting data to prepare a plan that should be the basis of the Substance Abuse Prevention and Treatment Block Grant application. This recommendation stemmed from a growing body of literature on substance abuse and mental health planning (Ford 1997; Frank 1985; Ingram 1988; Kimmel 1993; McKillip 1992; Maddock et al. 1988; NIAAA 1981; Goldsmith et al. 1992; Richards 1985; Ryan 1984-85; Schlesinger et al. 1994; Shapiro et al. 1985; Simeone et al. 1993; Soriano 1995; Wallack 1994; Warheit et al. 1977; Wilson and Hearne 1986; Cochran et al. 1997; Lo and Stephens 2000; SAMHSA 1997; CSAT 1999). Moreover, there is increasing recognition in the social sciences of the importance of needs assessment in education, health, and social services (Witkin and Altshuld 1995; Soriano 1995). These important works describe the basic epidemiological needs assessment methodologies to be used in this comprehensive study.

The basic needs assessment research model was described by the NTC in its telephone survey monograph (McAuliffe et al. 1995). New York pioneered this approach to treatment needs assessment (Frank 1985; Simeone et al. 1993; Welte and Barnes 1995). North Charles developed a similar statewide treatment services plan for Rhode Island a decade ago (McAuliffe et al. 1991). Rhode Island continues to use the plan for a broad range of policy and planning purposes, and Rhode Island currently has one of the most adequate supplies of treatment services in the country (McAuliffe et al. 1999a).

North Dakota's Needs Assessment Studies

North Dakota conducted two rounds of needs assessment studies. The first round of studies included a household telephone survey, a social indicator study, a survey of American Indians on reservations, and an integrated analysis. The Adult Household Survey (Gallup 1998a) interviewed 6,814 North Dakota residents aged 18 and older. The survey revealed that North Dakota adults had a low rate of substance use disorders relative to other states. Only 5.2% of the sample had a current substance use disorder (abuse or dependence). While 7.8% of those with a current treatment need received some in the past year, only 2% of those with a need that did not receive treatment in the past year expressed a desire for treatment. North Dakota's second Round One study was a social indicator study (Kraft 2000). The study used common indicators of substance abuse and treatment data to identify which service areas were in greatest need. The third Round One study was a face-to-face survey of American Indian adults on reservations that used the same instrument as the household survey (Gallup 1998b). The Round One studies also included an integrated analysis, however, the only portion of the need estimate from that study that had a diagnostic assessment was the household portion (Johnson, Bassin, and Shaw 1999).

The Round Two studies included a social indicator study, and the present integrated needs assessment. The social indicator study showed that North Dakotans suffered the lowest rate of social problems due to drug abuse in the United States (McAuliffe et al. 1999b). North Dakota ranked 14^th nationally in an index of alcohol abuse indicators. In a combined substance treatment need index, North Dakota ranked 24^th nationally. Analysis of the indicators within the state revealed that Human Service Regions I and III had the highest scores in an alcohol treatment need index.

The second Round Two study is this integrated treatment needs assessment. This final report seeks to combine previous estimates of treatment need for mutually exclusive population subgroups and to develop estimates for any groups not covered by one of the State's needs assessment studies in order to obtain a comprehensive, statewide estimate of need. This report will describe the estimates of need for each population subgroup including adults in households with telephones, people aged 12 and older in households without telephones, prisoners and juvenile detainees, the homeless, and adolescents. The report combines the needs of these groups to estimate total need and assesses the performance of the State's treatment system based on an analysis of the gap between need for treatment and treatment delivered (see chapter on gap analysis).

Organization of the Final Report

The next part of the report includes a review of the study's overall methodology, a chapter on historical trends in substance abuse needs and treatment services at the national level, and an analysis of how North Dakota's treatment needs compare to the treatment needs of other states. Those chapters are followed by a series of chapters that focus on the treatment needs of non-overlapping segments of the State's population. The first chapter presents the results for people in households with telephones, and the next chapter estimates the needs of residents of households without telephones. Another chapter addresses the needs of North Dakota's American Indian population (this population is not a component of the overall need estimate). The remaining chapters in the series address the needs of prisoners and the homeless. The next chapter combines the results for all subpopulations. The analysis examines the integrated statewide past-year need for treatment, the percentage of people in need who received treatment, and the unmet demand for treatment. The integrated estimate of treatment need for the entire state population will be used to identify the gap between treatment need and services provided at the statewide level. The North Dakota substance abuse indicator model is then used to distribute the needs across the State's regions. The penultimate chapter describes the results for the levels of care of those who need and want treatment, and it describes their own preferences for additional services. The last chapter of the report summarizes the results and presents a series of recommendations based on them.

References

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Substance Abuse and Mental Health Services Administration (SAMHSA), Office of Applied Studies and Research Triangle Institute. (1997). National Household Survey on Drug Abuse: Population Estimates 1996. Rockville, MD: U.S. Department of Health and Human Services.

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Witkin, Belle R. and James W. Altschuld. (1995). Planning and Conducting Needs Assessments: A Practical Guide. London: Sage Publications.

Methods

This chapter describes the study's research methodology. Development of an integrated needs assessment and plan requires a broad understanding of the treatment needs of the population (results of the family of studies), the resources currently available (from the utilization studies), and the policy and technical contexts in which the treatment system will be functioning in the coming years. Bringing together these three elements was the object of data collection and analysis for this study. To obtain this information, the study team used a series of methodologies, each selected to address a specific component in the process. The steps described below include: a review of the recent developments in substance abuse epidemiology, analysis of how North Dakota's services per unit of need compare to other states, background interviews with State substance abuse officials, a review of other relevant North Dakota studies and substance abuse literature, analyses of needs assessment data and findings from treatment utilization statistics, analyses of census data and prevalence statistics on special populations from the first round of studies and the literature, gap analyses comparing need and resource data, and analysis of the State's treatment system. In applying each of these methodologies, the study team attempted to determine the overall statewide level of need, substate area needs, and the appropriate treatment allocation. The specific questions addressed by each of the methods are described in Table 2.1. In fashioning plans to address the needs that have developed, the study team sought a clear picture of North Dakota's substance abuse treatment goals, what has been tried in the past, and how the treatment system will change in the future to address existing needs.

Description of Specific Methods

This comprehensive study will include a series of substudies described in Table 2.1. This section describes the methods employed in each of these study components:

A conference call with key officials

Review of prior related studies

Review of relevant literature and reports to analyze the substance abuse context: epidemics, long-term trends in treatment, and financing

Analysis of social indicator data

Analysis of interstate data on needs and services comparing North Dakota to other states

Integration of estimates from non-overlapping segments of the population

Analysis of needs and resources to identify gaps in amount of services, types of services, and location of services.

Any research, including a treatment needs assessment, should begin with hypotheses about what the study is likely to find or what the key questions are. Only then can one be sure that all of the essential data will be collected in the required form and all irrelevant data, no matter how "interesting" from an academic perspective, will be excluded. The hypotheses also inform the analysts of precisely what questions to ask of the data once it has been collected. The "Background Studies" in Table 2.1 are designed to be hypothesis generating.

Background Interviews

The study team conducted telephone interviews with agency officials who are knowledgeable about North Dakota's substance abuse treatment system and about groups that utilize the system (e.g. prisoners, homeless). Their perspectives and day-to-day experiences working within or with the treatment system were crucial to understanding how the system functions. Learning their ideas for change was critical for formulating recommendations. The interviews were semi-structured, with a series of questions devised by the study team prior to the telephone calls.

The calls covered the officials' roles in the system, perceptions of the system's performance in meeting the needs of North Dakotans, perspectives and recommendations for change, coordination issues, and service gaps. The objective of the calls was to develop specific recommendations about the treatment system's functioning.

Review of Prior Studies and Documents

North Dakota has conducted a number of previous studies and produced planning reports that served as background for the study. NCRPG obtained these studies and used them for this report.

Literature Review

Although every state is unique to some degree, the substance abuse problem is national in scope. Identifying relevant trends can help organize a range of facts. This understanding is critical when using the resulting data to develop a treatment needs assessment and plan for the State. Current trends that were important include the up-tick in use of drugs and the decline in alcohol use, increases in substance use disorders among prisoners, and widening of the treatment gap.

Social Indicator Study

NCRPG conducted a social indicator analysis to guide allocation of resources over substate regions for which the State's survey estimates are too imprecise (see McAuliffe et al. 1987, 1991 and Folsom et al. 1996 for a description of this use). Social indicator studies complement other studies using different methodologies (thus increasing validity) and thereby serve to strengthen a state's credibility when attempting to allocate substance abuse treatment resources equitably. Social indicator analyses are especially effective when used in conjunction with survey data. Because social indicator analyses provide relative differences, rather than absolute counts, household survey data can be used to provide a baseline from which to calibrate estimates for actual counts of need. Due to the small number of cases in substate areas, the combined telephone and supplementary surveys which comprise most of the family of studies are less reliable at the substate level than they are at the State level. As a result, the survey data may not be as effective for distributing resources over subareas as they are for estimating statewide need. Consequently, the social indicator study will be employed to supplement survey estimates and to estimate substate level estimates more reliably.

The study began with the selection of a small number of measures of need from different data sources or systems (i.e., substance-abuse related deaths and arrests). Data on substance-abuse related treatment admissions were also collected. Indicator selection is based on the measures' theoretical relationships with substance abuse treatment need, the results of previous validation studies, and data availability. County-level data were obtained for the selected variables. The data were cleaned, entered into a database, and then subjected to rigorous empirical reliability and validity testing.

The rationale for the initial selection of a small number of variables was that they are more manageable (e.g., can be cleaned and validated individually), explain most of the relevant variance in treatment service needs, and are more easily interpreted by both investigators as well as State officials and the public (Dembling et al. 1993; McAuliffe et al.1999). Experience in Rhode Island clearly indicates that the public will be interested in the validity of the index when the resulting resource allocations affect the relative availability of services in the State's substate areas (Breer et al. 1996).

Empirical research by the NTC (McAuliffe et al.1999) and by other states (Aktan, Calkins et al. 1997) has shown that the geographic location of alcohol problems often differs from the location of other drug problems. Analyzing individual indicators of both alcohol and other drugs together can obscure important information for planning purposes (e.g., where to locate drug-specific programs versus where to locate alcohol detox facilities).

Interstate Comparisons

It is useful to compare the State's treatment needs with those of other states in order to have a basis for evaluating the adequacy of its treatment services. Recent examples of interstate alcohol and drug treatment comparisons include McAuliffe et al.(1999; 2000). Following the analysis reported by Dayhoff et al. (1994) with regard to alcohol treatment services for all states, this study analyzed interstate differences with regard to both alcohol and drug treatment.

Uncovered Population Estimates

NCRPG has estimated that 90% of all people with substance use disorders nationwide live in households with telephones (Geller 1995). As a result, the backbone of the NCRPG model family of studies is the specially designed household telephone survey conducted by North Dakota in its first round of studies. Nevertheless, there are important treatment populations in which the percentage living in households with telephones is smaller. A recent face-to-face survey of household and nonhousehold residents of the Washington, DC metropolitan area revealed that failing to include nonhousehold populations would have little impact on the overall rates of illicit drug use, but it would result in a 20% underestimation of past year heroin and cocaine users (Gfroerer 1996).The Epidemiologic Catchment Area Survey (ECA) studies had previously included studies of nonhousehold populations to respond to this problem.

North Dakota surveyed American Indians living on reservations in order to obtain estimates for that group that were not biased due to low telephone coverage. One objective of the integration study is to employ data from such studies in order to reinforce the more comprehensive estimates of treatment need outlined below. Because all relevant groups were not covered in the North Dakota family of studies, the current study team developed estimates of the State's need estimates by obtaining statistics on the prevalence rates for the omitted groups and obtaining estimates of the size of the groups from census data (Geller et al. 1997; McAuliffe et al. 1998). The data to be used for this estimation process include estimates of numbers of adults in households without phones, adolescents, and the homeless. In addition to its own surveys of special populations such as the homeless (recently completed in Rhode Island), the study team conducted a series of literature reviews to obtain estimates of the prevalence of substance abuse treatment need for these groups from a literature search of such major databases as MEDLINE, PSYCHINFO, and HEALTHSTAR, adjusting the estimates so that they capture the correct age range and both past-year and lifetime prevalence. The number of persons in need of substance abuse treatment in each uncovered population was estimated by multiplying the adjusted prevalence rates for each of these populations by the number of members of these populations in North Dakota.

Gap Analysis

A central feature of this study was to bring together the State's data on treatment needs and resources. Many important questions about subgroups, substate areas, and the State as a whole will be addressed concerning the amount, type, and location of treatment needs and services. For example, what percentage of the population needed treatment, and what proportion of the people in need wanted to obtain services? What reasons did they cite that prevented them from obtaining treatment? Finally, the analysis identified the gaps in services by comparing the need and demand for services with the services that were available.

Conclusions and Recommendations

The report includes proposals regarding how the treatment system should respond to fill the gaps in treatment and meet the challenges of the coming years. The recommendations stemmed from analysis of the estimates of treatment gaps, the State's service mix, and the perspectives of State officials.

References

Aktan, Georgia B., Richard F. Calkins, Rafa M. Kasim, Sandra Kimball, and Karen Schrock. (1997). Social Indicators Modeling for Substance Abuse Treatment Needs Assessment Substance Abuse Need Index (SANI). Michigan Department of Community Health.

Breer, Paul, William E. McAuliffe, and Eliot B. Levine. (1996). "Statewide substance abuse prevention planning." Evaluation Review. 20(5): 596-618.

Dayhoff, D.A., G.C. Pope, and J.H. Huber. (1994). "State Variations in Public and Private Alcoholism Treatment at Specialty Substance Abuse Treatment Facilities." Journal of Studies on Alcohol. 55(5): 549-560.

Dembling, Bruce. (1993). Distribution of Consumer Demand for a Public Psychiatric Hospital: Application of a Geographic Information System. National Conference on Mental Health Statistics.

Folsom, Ralph E., Judith T. Lessler, Michael B. Witt, Joseph C. Gfroerer, Douglas A. Wright, and Joseph Gustin. (1996). Substance Abuse in States and Metropolitan Areas: Model Based Estimates from the 1991-1993 National Household Surveys on Drug Abuse, Summary Report. Substance Abuse and Mental Health Services Administration (SAMHSA), Office of Applied Studies (OAS). Rockville, MD: U.S. Department of Health and Human Services.

Geller, Stephanie. (1995). "Supplementary Studies: Introduction" Proceedings of the 1995 Newly Funded States Workshop: Measuring Need for Substance Abuse Treatment and the Implications of Managed Care. Cambridge, MA: National Technical Center (NTC).

Geller, Stephanie, W.E. McAuliffe, and P.A. Minugh. (1997). Bulletin #14: Combining Subpopulation Estimates to Develop Comprehensive Estimates of Treatment Need. Cambridge, MA: National Technical Center (NTC).

Gfroerer, J.C. (1996). "Special Populations, Sensitive Issues, and The Use of Computer-assisted Interviewing in Surveys." Health Survey Research Methods: Conference Proceedings. Hyattsville, MD: U.S. Department of Health and Human Services. 177-180.

McAuliffe, W.E., P. Breer, N. White, C. Spino, L. Goldsmith, S. Robel, and L. Byam. (1987). A Drug Abuse Treatment and Intervention Plan for Rhode Island: Review Copy. Cranston, Rhode Island: Rhode Island Department of Mental Health, Retardation and Hospitals, Division of Substance Abuse.

McAuliffe, W.E., P. Breer, N.W. Ahmadifar, and C. Spino. (1991). "Assessment of Drug Abuser Treatment Needs in Rhode Island." American Journal of Public Health. 81(3): 365-371.

McAuliffe, W.E., S. Geller, R.A. LaBrie, S.B.F. Paletz, and E.A. Fournier. (1998). "Are Telephone Surveys Suitable for Studying Substance Abuse Epidemiology? Cost, Administration, Coverage and Response Rate Issues." Journal of Drug Issues. 28(2): 455-482.

McAuliffe, W.E., R.A. LaBrie, N. Pollock, N. Lomuto, E.A. Fournier, R. Betjemann. (1999). "Measuring Interstate Variations in Drug Abuse." Drug and Alcohol Dependence. 53(2): 125-45.

McAuliffe, William E., Richard A. LaBrie, Nicoletta A. Lomuto, Nancy E. Pollock, Rebecca Betjemann, and Elizabeth Fournier. (2000). "Measuring Interstate Variations in Problems Related to Alcohol Use Disorders." Eds. Robert A. Wilson and Mary C. Dufour. The Epidemiology of Alcohol Problems in Small Geographic Areas. First ed. Bethesda, MD: National Institute on Alcohol Abuse and Alcoholism (NIAAA). 213-244.

National Trends

This chapter examines epidemiological evidence regarding national trends that affect individual states. As the next chapter will show, every state has its unique history and profile with regard to alcohol and drug abuse. However, history reveals convincingly that most substance abuse problems have a national or regional basis (Hunt 1974). The national heroin addiction epidemic of the 1950s got its start in Harlem (Brown 1965), and the psychedelic epidemic of the 1960s and 1970s began at Harvard and in California. Cocaine gained in popularity as a national media phenomena. The AIDS epidemic among injection drug users was first detected in New York, New Jersey, and Maryland (McAuliffe and Ackerman 1991). Only several years later did the prevalence of HIV become painfully evident in other states away from those epicenters. In the past decade, similar national trends in adolescent drug use and use of "club drugs," especially "ecstasy," have spread across the country (Community Epidemiology Work Group 2001). While regions and states may vary in their vulnerability to specific epidemiological trends, states can ill afford to ignore these developments. In the present context, these national trends help explain the current treatment needs in individual states. The remaining sections will describe national trends in alcohol and drug abuse and services over the past decade. The Data Sources appendix presents the citations for the sources of the statistics presented in this chapter.

Alcohol Treatment Needs

Indicators of alcohol use, dependence, and adverse consequences over the last decade suggest that the need for alcohol treatment services has not increased, except possibly among adolescents. Measures of national consumption of alcohol peaked at the beginning of the 1980s, and then diminished thereafter (Office of Applied Studies 2000c; Greenfield et al. 2000). Per capita alcohol consumption (gallons of ethanol per person 14 and older) declined from 1990 to 1995, and it remained more or less stable thereafter (Figure 3.1; Nephew et al. 2000). As shown in Figure 3.2, the percentage of National Household Survey on Drug Abuse (NHSDA) respondents who drank alcohol in the past year also tapered off throughout the late 1980s to 1998. An even steeper decline occurred among the survey's adolescent respondents.

Starting in 1985, survey estimates of heavy drinking in the past month (Figure 3.3) declined gradually, although that rate increased somewhat in 1998 (Office of Applied Studies 1999a, p. 34; 2000c, p. 31). Heavy drinking by the NHSDA's adolescent respondents increased slightly between 1994 and 1995, after a sharp decline in the late 1980s and early 1990s (Office of Applied Studies 2000c).

The rate of alcohol dependence symptoms in the 1984, 1990, and 1995 National Alcoholism Surveys increased slightly over time but there were no significant differences between it and the NHSDA (Figure 3.4; Midanik & Greenfield 2000). Because the NHSDA Main Findings include only rates of alcohol dependence symptoms, the authors analyzed NHSDA public-use data sets in order to find a dependence diagnosis rate. The rates of persons having three symptoms of dependence were higher than the diagnosis rates, but both held to the same upward trend between 1995 and 1998, the years for which the public-use data sets are available. Because the survey questions on symptoms changed between 1994 and 1995 and because the 1999 Main Findings focused on the dependence diagnosis rate rather than symptoms, Figure 3.4 does not include NHSDA estimates for years earlier than 1995 or later than 1998. The apparent differences between the National Alcoholism Survey and the NHSDA estimates, which is not unlike differences in the prevalence rates reported by the Epidemiological Catchment Area study and the National Comorbidity Survey, raises questions about how useful these survey estimates of alcohol dependence are for trend analysis and policy making (Regier et al. 1998).

Among the arrest categories that may be referred to as "alcohol-defined," the rates of arrests for driving under the influence (DUI) and for drunkenness showed the sharpest decreases (24%) between 1991 and 1998 (Figure 3.5). Disorderly conduct arrest rates, which often include arrests for drunkenness ( "drunk and disorderly"), were also down (9%) in that period. The one exception to this trend was the rate of arrests for liquor law violations, which increased 10% between 1991 and 1998. Between 1993 and 1996 liquor law violation arrests increased 32%. Liquor law arrests in part reflect underage drinking, which surveys suggested began increasing in 1995.

Figure 3.6 shows that alcohol mortality rates fell between 1989 and 1999. Three different measures displayed this pattern. A clear reduction is evident in the Centers for Disease Control's (CDC) "alcohol-induced" underlying cause mortality rates. Similarly, the National Institute on Alcohol Abuse and Alcoholism's (NIAAA) age-adjusted mortality rates with explicit-mention of alcohol as an underlying cause, which employs the same set of diagnoses as the CDC measure, sunk from 7.3 per 100,000 to 6.4 per 100,000 over the same period. While the age-adjusted rates are consistently lower than the crude rates, they follow virtually the same trend, suggesting that age alone cannot account for the drop. Finally, alcohol-related motor vehicle deaths (defined as alcohol-related by the investigating officer's judgment or a positive reading from any one of several blood tests), reported by the NIAAA from Fatal Accident Reporting System (FARS) data, dropped even more sharply than the other two indicators (Yi et al. 2000). Accidental deaths are not included in the explicit-mention indicators. These results are consistent with the sharp drop in DUI arrests just described.

Alcohol Treatment

Private spending for alcohol treatment went up 250% in the decade between 1979 and 1989 (Dayhoff et al. 2000). Across the country, the percentage of employees at large and medium-sized firms who had coverage for hospital detoxification increased two and one-half times from 37% in 1982 to 96% in 1989 (Dayhoff et al. 2000). Dayhoff et al. (2000) reported that national public spending for alcohol services increased 60% in the decade between 1979 and 1989. In the early 1990s, total public spending for alcohol and drug specialty treatment services continued increasing by 5%, largely due to the broadening of Medicaid coverage of substance abuse treatment and a 25% increase in the federal Alcohol, Drug and Mental Health Services Block Grant. However, individual state and local government spending for substance abuse services declined (16% and 31% respectively) in the first four years of the 1990s, thus dampening the continuing trend towards greater availability of public treatment services.

Three measures of the amount of alcohol treatment services from the OAS indicated that national alcohol treatment rates descended steadily from 1992 to 1999 (Figure 3.7). The three measures were primary alcohol treatment admissions (public specialty) from the Treatment Episode Data Set (TEDS), alcohol-only treatment clients (public and private specialty) from the National Drug and Alcohol Treatment Unit Survey (NDATUS)/Uniform Facilities Data Set (UFDS), and the percentage of NHSDA respondents that reported receiving treatment for alcohol use in the past year. The context in which the NHSDA's treatment question is asked in the national survey's interview suggests that "treatment" may include the specialty treatment measured in the UFDS and TEDS estimates as well as treatment provided in an emergency room, private doctor's office, prison, or self help group.

While the TEDS admission rate and the NDATUS/UFDS alcohol-only client rate fell steadily throughout the period, the NHSDA treatment statistics described a much steeper decline. It is also noteworthy that the estimated number of clients in the NHSDA series was much higher than the NDATUS/UFDS series that includes both private and public services.

Alcohol Treatment Gap

Although the alcohol treatment need and service indicators were not always perfectly in step, they mostly indicated stabilization or decline in alcohol use, problems, and services. To measure the relative changes between the measures of treatment need and treatment services, the authors divided the service rates by the need indicators. The ratio of treatment to the percent alcohol dependent in the NHSDA declined from 1995 to 1998 regardless of the measure of services, although the extent of the widening of the treatment gap depended greatly on which measure of services the analysis employed (Figure 3.8). The ratio of the percentage of NHSDA respondents who received alcohol treatment in the past year relative to the number who had a current alcohol dependence diagnosis dropped from a high of .383 in 1996 to .216 two years later. The last number suggested that less than one respondent received treatment in the past year for every four respondents who had a current alcohol dependence diagnosis. Note that because of the way these gap ratios were designed - the treatment rates are in the denominator while the need indicators are in the denominator - a smaller ratio represents a wider treatment gap. So, in the gap analysis graphs (for example, Figure 3.8), a line that goes down over time shows a widening in the treatment gap. The present analysis does not indicate whether the respondents who received treatment were the same ones that had an alcohol dependence diagnosis. It is also noteworthy that the NHSDA's dependence measure is a point prevalence referring to the percentage who had a diagnosis at the time of the interview. It does not indicate how many people had a diagnosis at any time during the year. By contrast, the treatment measure describes the percentage of respondents who received treatment for alcohol at any time during the past year. Thus, this ratio is conservative and may underestimate the true alcohol treatment gap, but it seems likely that the trend is reasonably accurate.

When the measure of treatment was the rate of admissions for publicly-funded specialty alcohol treatment according to the TEDS database, the decline was from .103 in 1995 to .074 in 1998. The variation between these three measures suggests that part of the task in measuring the national gap in alcohol treatment is to determine how best to measure the amount of treatment services that were provided each year.

When the measure of treatment in the numerator of the ratio was the UFDS/NDATUS alcohol-only rate, the decline relative to the percent dependent was more gradual, going from a peak of .037 in 1995 to .024 in 1998. The alcohol-only NDATUS/UFDS statistics describe a point prevalence of both public and private specialty treatment, but this measure excludes people who received treatment for both alcohol and drug problems. In some years, the excluded persons with both drug and alcohol treatment needs were nearly equal to the number of alcohol-only clients, while in other years they were nearly twice as numerous as the alcohol-only clients.

When assessing the gap between treatment and dependence, it is important to consider the amount of treatment services delivered to those in need of treatment for alcohol dependence. One of the ratios of services to dependence cited above measures all services reported by NHSDA respondents relative to all respondents that had a dependence. That is why the ratio for NHSDA treatment services to NHSDA dependence is the highest. The other treatment measures, the UFDS and the TEDS, capture only clients at specialty treatment facilities where all clients are likely to have a diagnosis, whereas the NHSDA data capture people in non-specialty treatment that may or may not have had a diagnosis in the past year.

As shown in Figure 3.9, the percentage of those with a past year diagnosis for alcohol dependence that received treatment in the past year declined steadily between 1995 and 1997, then dropped by more than three percentage points over the next year. The percentage of respondents with a past year alcohol dependence that received treatment in the past year in 1998 (6.58%) was less than two-thirds the rate in 1995 (10.72%). That trend was consistent with the trend shown in Figure 3.8 that compared treatment rates with the dependence rate regardless of whether those who received treatment were dependent.

Comparison of the ratio between the NHSDA past-year alcohol treatment and NHSDA diagnosed past-year alcohol dependence with the rate of treatment among those with a dependence diagnosis revealed that there were many respondents in each year that did not have a dependence diagnosis, but received treatment for alcohol use. Consider that the gap ratio indicated that the number that received treatment was about 37% of the number with a dependence diagnosis in 1995, while the treatment rate among NHSDA respondents with a diagnosis was less than 11% in that year. There are several reasons for this disparity. First, about 71% of those who said they received treatment for alcohol in 1995 did not have a diagnosed alcohol dependence. The NHSDA data do not permit diagnoses of non-dependent abuse. Those people are considered to be in need of treatment and it is likely that many of those without a diagnosis for dependence that received treatment would have met the criteria for abuse. Second, the treatment question in the survey is designed to capture a broad range of treatment types including non-specialty modes such as, participation in self-help groups, counseling, and consultation with a private doctor. As such, the treatment group may include respondents that had a lifetime diagnosis of abuse or dependence, but were in full remission at the time of the survey. Third, a diagnosis is for the whole year, but the survey only counts from the time of the survey itself. For example, a respondent might have had a diagnosis 13 months prior to the survey and still manifested symptoms during the time of the survey, but had only one or two symptoms and would therefore, not be diagnosed as dependent when he should have been.

For those reasons, it is difficult to state with certainty whether treatment among those with a diagnosis is the estimate most relevant to needs assessment or if a comparison of treatment against need is the correct measure. The correct estimate probably lies somewhere in between. A correct treatment need estimate measures both dependence and abuse and evaluates respondents for a diagnosis over the whole period, rather than gauging only symptoms over the past year. To confirm the inferences derived from using the NHSDA measure of dependence in the denominator, the authors replaced it with arrest and mortality indicators. The first analysis combined alcohol arrest rates (DUI, drunkenness, and liquor law violation arrests) and divided the measure into treatment as measured by the NHSDA, the NDATUS/UFDS client survey, and the TEDS admissions data (Figure 3.10). As before, the extent of the increase in the treatment gap depended on which measure the analysis used. The gap grew sharply when treatment was measured by the NHSDA estimate of the number of persons who received treatment in the past year. When the numerator was the NDATUS/UFDS estimate of people in treatment on a given day and the denominator was the number of people who were arrested in the past year, the gap widened only gradually. When the TEDS treatment measure was used as the numerator of the gap ratio, the gap increased gradually starting in 1994 and stabilized in 1997.

When the CDC's alcohol induced crude mortality rate in a year was the denominator, the trends remained basically the same as for when the survey dependence estimates or arrest rates were in the denominator of the ratio of treatment to need (Figure 3.11). The major determinant appears to be how treatment is measured rather than how need is measured. With NHSDA estimates of the number of persons who received treatment in the past year in the numerator, the treatment gap widened sharply over the period. With the NDATUS/UFDS survey estimates of static capacity in the numerator and alcohol-induced mortality in the denominator, the treatment gap widened more gradually over the period. The ratio of the TEDS treatment admissions rate to the alcohol-related mortality rate indicated a trend in the treatment gap very similar to the trend indicated by the gap measure that employed the NDATUS/UFDS treatment estimate.

Drug Abuse Treatment Needs

National surveys found that use of most illicit drugs decreased sharply during the 1980s, but then drug use rates (including marijuana, cocaine, and heroin) increased during the early 1990s, especially among youths (OAS 2000c, p. 30). The consumption of cocaine in particular declined to much lower levels since the mid 1980s (OAS 1999a, p. 32). For example, the percentage of persons aged 18 to 25 who reported using cocaine in the past year declined from 14% in 1985 to 4% in 1997. That age cohort routinely had the highest rates of controlled drug use. Past-month use of marijuana by this age group declined from 22% in 1985 to 11% in 1992. Beginning in 1993, past-month use of marijuana increased slightly until 1997, when it declined slightly to a rate (13%) that was still well below the peak year of 1979 (37%) and below the 1985 rate (22%). Statistics from the Monitoring the Future survey of youth also found that marijuana use began increasing between 1993 and 1997 before tapering off in 1998 and 1999 (Office of National Drug Control Policy [ONDCP] 2000). Cocaine initiations also turned upward in early 1990s. Statistics from the NHSDA indicated that past-month heroin use increased from 1990 to 1997 to levels that exceeded 1985 before dropping back down to 1985 levels in 1998 (Epstein and Gfroerer 2001; ONDCP 2000). With some exceptions, current levels of nonmedical controlled drug use are lower than 1985 levels despite increases since 1992 (ONDCP 2000).

The survey self-reports of dropping drug use were confirmed by urine test results from employee testing. Figure 3.13 shows that the percentage of positive urine testing conducted by employers around the country dropped steadily from 13.6% in 1988 to 4.6% in 1999 (Quest Diagnostics, Inc. 2000). The increases in drug use, most evident among adolescents, has apparently not yet begun to affect employee testing data significantly, although some flattening of the rate of decline is apparent in 1997-1999.

Drug Dependence

The authors analyzed NHSDA public-use data sets to obtain rates of drug dependence for the years 1995 through 1998. In order to illustrate the extent to which that dependence measure is overwhelmingly composed of marijuana and cocaine users, the drug dependence measure is graphed alongside NHSDA estimates of the rate of the population 12 and older that experienced at least three problems due to use that are components of a dependence diagnosis (Figure 3.14). The questions on problems stemming from use changed between 1994 and 1995 and, as such, fluctuations between those years may be exaggerated. Clearly, the overall drug dependence rate rose between 1995 and 1996, then remained constant at 1,770 per 100,000 in the population thereafter. The rate of having three problems due to cocaine or marijuana use remained reasonably steady, as well.

The total number of drug-related emergency room episodes recorded in the Drug Abuse Warning Network (DAWN) has increased from 1990 (Figure 3.15; Caulkins 2001; OAS 2001; ONDCP 2000). The number of emergency room visits for drug-related episodes declined briefly in 1995, but then increased steadily from 1996 to 1999. The most common drug mentions continued to be cocaine-related problems (Caulkins 2001), apparently resulting from long-term consequences of chronic use according to the ONDCP (2000). In the mid 1990s, the consequences of growing use of "club drugs" (MDMA or "ecstasy" and GHB) as well as prescription opiates (hydrocodone and oxycodone) began to show up in DAWN emergency room statistics (Substance Abuse and Mental Health Services Administration [SAMHSA] 2001). The sharpest increases in mentions of the club drugs occurred in the period between 1998 and 2000.

Arrests for drug abuse violations rose nationally in the past 15 years. From 1985 to 1995, drug abuse violation arrests rose 82% (Federal Bureau of Investigation [FBI] 1996, p.280), and by 1999 drug arrests were 7% higher than the same statistics in 1995. In 1999, drug arrests were 36% higher than they were in 1990. By contrast, arrests were down 1% for all offenses, 9% for violent crimes, and 26% for property crimes during the same period (FBI 2000, p.211). As shown in Figure 3.16, Uniform Crime Reports (UCR) drug arrest rates increased steadily from 1991 to 1998, with a noticeable increase in 1994, which may be a methodological artifact resulting from the change over of many states to the FBI's new reporting system that permits tabulation of drug arrests that were not the most serious crime in the episode.

Drug Mortality

Drug mortality rates from three data sources suggest the same trend: up (Figure 3.17). The rate of explicit-mention drug deaths using the present authors' (North Charles Research and Planning Group's [NCRPG]) set of diagnoses from multiple cause data supplied by the National Center for Health Statistics (NCHS) of the CDC closely parallels the "drug-induced" mortality underlying cause rate published by the CDC. The primary difference between the two rates is the use of multiple causes in the NCRPG measure and inclusion of overdoses due to suicide, assault, and undetermined external causes for some drugs in the drug-induced measure ( CDC 1993). The authors also included a measure based on the DAWN medical examiner statistics and the total population. Readers are cautioned not to interpret the absolute level of the DAWN rates as comparable to the other rates, since the DAWN deaths come mainly from urban areas. Lacking the relevant population base for the DAWN statistics, the authors used the total population as a proxy for indicating changes in population over time. The DAWN medical examiner data stem from the investigations of a panel of medical examiners (138 up to 1995, and 134 thereafter) (see Data Sources). In 1996, estimates were available for both sets of panels, and the results did not differ when rounded to one decimal. The medical examiner data include deaths due to suicide (ONDCP 2000). The obvious correlation between the three series suggests the basic validity of all three measures, which is important given the limited geographic coverage of the DAWN medical examiners data.

It is noteworthy that the average purity of retail heroin increased in 1992 and 1993 and has remained at high levels ever since, and the price per gram declined steadily after 1991 (ONDCP 2000). It is likely that increases in purity and decreases in price contribute to the increase in the prevalence of use and to the prevalence of drug overdoses by users.

Summary of Drug Treatment Need Indicators. The drug indicators revealed some inconsistency, but the overall trends were reasonably clear. Employee-testing and self-reported overall drug use by persons 12 and older went down steadily during the 1980s and the first few years of the 1990s, but the past month drug use by adolescents, drug mortality, emergency room episodes, and arrest statistics for the entire population increased in the decade of the 1990s; especially during the middle of the decade.

Drug Abuse Treatment

Contrasting trends were apparent in the measures of treatment services received during the 1990s. All three measures are maintained by the OAS and are shown in Figure 3.18. Whereas the TEDS primary drug treatment admissions reported by states and the NDATU/UFDS drug-only treatment clients increased over the period, the NHSDA's estimates of the number of persons who received treatment in the past year declined after a spike upward in 1996. Federal funding of treatment increased by 35% between FY1996 and FY2001 (ONDCP 2000).

It is noteworthy that the absolute rates among the NDATUS/UFDS clients and the NHSDA's estimates of the number of clients differed by between seven and ten-fold in the period. This difference contrasts with the assertion by the NHSDA's top analysts that the "NHSDA undercounts . . . drug clients treated" (Woodward et al. 1997, p. 8). In previous research, the present authors found that the interstate NDATUS rates for 1991-1993 did not correlate with the NHSDA's estimates of treatment received in the same years (McAuliffe et al. 1999). The lack of correlation among the indicators raises questions about the planned use of the NHSDA to measure the drug treatment gap (Woodward et al. 1997).

Drug Treatment Gap

Due to the inconsistency between the measures of treatment services, the measures of treatment relative to indicators of treatment need were also inconsistent. Because the authors were unable to obtain published NHSDA estimates of dependence on any controlled drug for more than two years, this study uses measures created from the NHSDA's public-use databases for 1995-1998.

The ratio of the NHSDA's estimates of the percentage of respondents who received treatment in the past year to the NHSDA's estimate of the percentage of respondents who had a drug dependence diagnosis at the time of the interview indicated an increasing drug treatment gap. That is, the proportion of persons in need that received treatment declined. Recall that in the alcohol treatment gap analysis, a smaller ratio of treatment to need indicators indicated a larger treatment gap. Hence, a graph line that shows a treatment to need indicator ratio decreasing over time shows a widening of the treatment gap. The greatest dip was in 1998 for which there was a published drug dependence estimate. By contrast, the ratio of the NDATUS/UFDS drug-only client rate to the percent with a drug dependence between 1995 and 1998 and the TEDS primary drug treatment admission rate to the percent who were drug dependent between 1996 and 1998 indicated a slightly decreasing gap in treatment relative to need. The TEDS-based measure declined only slightly between 1997 and 1998 and the NDATUS/UFDS-based measure increased slightly between 1997 and 1998, but the NHSDA-based series declined sharply from a peak in 1996 (Figure 3.19). In most years the NHSDA-based series moved in the opposite direction from the TEDS measure. Because Woodward et al. (1997) indicated their own concerns about the NHSDA's estimates of treatment, readers may prefer to place greater reliance on the other two measures.

It is important to examine the extent to which those with a current dependence on illicit drugs receive treatment. In the treatment need literature this is referred to as "met demand" for treatment. The treatment data from the NHSDA used above do not discriminate between those that received treatment for a dependence in the past year and those that received treatment, but had no past-year dependence. The UFDS and TEDS treatment data are assumed to capture mostly people with a substance abuse problem because those data sets are collected from specialty treatment facilities. The question on past-year treatment in the NHSDA is designed to capture a variety of treatment modes including self-help groups, all types of counseling, and consultation with a private physician. As shown in Figure 3.20, the percentage of those with a drug dependence that received some treatment in the past year peaked in 1997 at almost 19%. That was up by over five percentage points from 1995. The rate tumbled by almost six and a half percentage points the next year. The proportion of those with a drug dependence that got treatment fell by a little over 1 percentage point over the period 1995 to 1998 and the rate fell by about a third between 1997 and 1998. This decline in services among those with a diagnosed dependence is similar to the decline in services among those with a diagnosed alcohol dependence, but it started several years later.

Comparison of the gap ratio of reported drug treatment to drug dependence with the treatment rate among those with a diagnosed dependence, prompts similar concerns as was the case with the measures of the alcohol treatment gap. The reasons for the difference are similar, as well. The treatment measure used in the gap ratio measures all treatment while the met demand measure captures only treatment among those in need. In 1995, 73% of those that reported receiving drug treatment in the past year had no past-year dependence diagnosis. The survey question on treatment is designed to encompass a variety of treatment modes, so the measure may capture people in full sustained remission. It is also likely that the treatment measure includes people who would meet the criteria for a drug abuse diagnosis, which the NHSDA does not measure. Further, the survey only measures dependence at the time of the survey. Therefore, the dependence measure fails to capture those who had a dependence or abuse diagnosis over the past year, but had less than three dependence symptoms at the time of the survey. It is impossible to determine from the NHSDA data how many of those that received treatment in the past year should have been diagnosed as dependent or as an abuser but were missed by the survey. Further, it is impossible to determine how many were in full sustained remission and received treatment. Finally, people in long term outpatient treatment, such as methadone maintenance, would be counted as having received treatment, but were in partial remission and not counted as dependent. Because the rate of treatment need includes more than just those with a dependence and because the NHSDA fails to identify some of those with a treatment need, the gap ratio is included here.

Replacing the NHSDA drug dependence estimates with drug arrests as the measure of need eliminated some of the differences between the treatment need and supply measures, but inconsistency between the NHSDA's measure of treatment and the other two indicators of treatment persisted. The NHSDA-based treatment measure suggests a substantial increase in the treatment gap over time, while the other measures suggest a more stable relationship between services and need over time (Figure 3.21). While both the NDATUS/UFDS-based and TEDS-based measures indicated a broadening of the treatment gap, the amount was small in both cases.

Using the drug mortality rate as the measure of drug treatment need, the authors found that the basic findings remained unchanged. For this analysis, the authors used the crude drug-induced underlying cause mortality rate from the Vital Statistics program of the CDC (1999) because the variable had more data points than the other measures of drug mortality had. As shown in Figure 3.22, all three ratios indicated a broadening drug treatment gap, but the amount was much greater for the ratio using the NHSDA treatment measure than the ratios using the other two measures (TEDS and UFDS/NDATUS).

Summary

Analysis of survey, arrest, mortality, emergency room, and treatment statistics revealed several national trends. Alcohol treatment needs declined during the 1990s as part of a long-term trend, but the alcohol treatment gap appeared to widen somewhat because the number of persons receiving treatment declined more rapidly than the indicators of need declined. Drug use declined sharply in the 1980s and the very beginning of the 1990s, but increased thereafter, especially in the middle of the decade. Adolescent drug use increased notably, just as heavy alcohol use by adolescents increased. Emergency room episodes followed a similar pattern. Notable increases occurred as a result of use of club drugs. Drug arrests and mortality increased steadily during the decade. The percentage of persons who were dependent on drugs was stable from 1994 to 1998. The drug treatment gap appeared to be widening in the late 1990s, substantially according to NHSDA treatment statistics, but much more moderately according to treatment admission and client statistics. Thus, there was some indication of a widening of the treatment gap for both drugs and alcohol in the late 1990s, even though alcohol treatment needs were declining while drug treatment needs were growing. The total number of clients in treatment for both drug and alcohol according to UFDS statistics remained essentially constant between 1992 and 1997 (ONDCP 2000). A substantial increase occurred in 1998.

Appendix: Data Sources

Alcohol and Drug Mortality Rates

There are four measures of mortality used in this chapter. For the multiple cause of death data, the NCHS of the CDC provided the authors with disks containing death certificate data for 1991-1996. NCHS nosologists, using special software, coded each cause of death from death certificates according to the International Classification of Diseases, Ninth Edition (ICD-9) (NCHS, 1998; Hopkins et al. 1989).

Each death record contained information on the decedent's demographics, residence, a code for the underlying cause of death, and the contributing conditions, including as many as 20 "entity-axis" and 20 "record-axis" codes (NCHS, 1998). The authors extracted all records that included at least one cause-of- death code with explicit mention of alcohol or controlled drugs in any of the 41 cause-of-death fields. It was possible for a death that was counted as having a drug diagnosis also to have one or more explicit-mention-of-alcohol diagnoses as well; similarly, a death counted as having an alcohol diagnosis could also have a explicit-mention drug-related diagnosis.

The explicit-mention drug codes used in this measure included drug psychoses (292.0, 292.1, 292.2, 292.8, 292.9), drug dependence (304.0 to 304.9), nondependent abuse of drugs (305.2 to 305.7, 305.9), and accidental poisoning. The ICD-9 codes for accidental poisoning are supposed to include combinations of poisoning nature ("N") codes for controlled drugs and external ("E") codes which indicated that the poisoning was accidental. As explained in the next paragraph, the authors also included deaths that had E-codes indicating undetermined external causes for some drugs of abuse, but did not include deaths due to suicide, therapeutic accidents, or assault. The N codes included deaths associated with ingestion of opiates (965.0), other specified analgesics (965.8), sedatives (967.0 to 967.9), other gaseous, intravenous, and surface anesthetics (968.2, 968.3, 968.5), benzodiazepines (969.4), other tranquilizers (, 969.5), hallucinogens (969.6), psychostimulants (N969.7), parasympatholytics (971.1), and dietetics (977.0). The relevant accidental or undetermined intent E codes included E850.0-E850.2, E850.8, E851, E852, E853.2, E853.8, E854.1, E854.2, E855.1, E855.2, E855.4, E858.8, E980.0, and E980.4.

The combinations of N and E codes varied depending on the drug. All deaths with the relevant N and accidental E codes were considered cases. In some instances, the records did not have both an N code for poisoning and an E code. Deaths that lacked an N code but had an accidental poisoning E code for a drug of abuse were counted as relevant cases. Deaths due to undetermined external causes for opiates, cocaine, and dietetics were also considered cases because the large majority of deaths associated with these substances had accidental E codes in national 1994-1996 mortality data. Deaths with an N code for opiates or cocaine (surface and infiltration anesthetics), but no E code, were treated the same as cases that had an undetermined E code. A full count of all drug deaths was divided by the Census Bureau's total population estimate (Census 2000), then multiplied by 100,000 to obtain a rate of drug deaths for each year, 1991-96.

Annually, the CDC publishes alcohol-induced and drug-induced death rates in its "Vital Statistics" series (CDC 1999, 2001). These rates reflect the underlying cause of death. The age-adjusted rates are published alongside the crude rates. These drug data differ from the explicit-mention rates developed by the authors from mortality files in that the CDC measure includes E codes for suicides, assaults and undetermined causes for some drugs not included in explicit-mention counts. With the possible exception of combinations of N and E codes for alcohol poisoning deaths, the CDC's alcohol-induced mortality rate uses the same diagnostic categories as the present authors used in developing their rates. The 1999 CDC deaths were coded using ICD-10 codes, whereas the previous years reflect ICD-9 coding. The CDC provided a crosswalk in the appendix of the 1999 preliminary report that makes the differences in coding clear (CDC 2001). While the CDC cautioned against comparisons across ICD-9 and ICD-10 codes, review of the trends presented in this chapter did not reveal any obvious discontinuity in the trends from previous years.

Alcohol mortality data from the NIAAA (Stinson et al., 1996) included any case with the underlying cause of death listed as one of the widely used explicit-mention alcohol diagnoses (e.g., McAuliffe et al., 2000; Stinson et al., 1994, 1996). The explicit-mention alcohol ICD-9 codes were 291 (alcoholic psychoses), 303 (alcohol dependence), 305.0 (alcohol abuse), 357.5 (Alcohol Polyneuropathy), 425.5 (Alcohol Cardiomyopathy), 535.3 (Alcohol Gastritis), 571.0 (Alcoholic fatty liver), 571.1(Acute Alcoholic Hepatitis), 571.2 (Alcoholic Cirrhosis of the Liver), 571.3 (Alcoholic Liver Damage, Unspecified), 790.3 (Excessive Blood Level of Alcohol), E860.0 (Accidental Poisoning by Ethyl Alcohol Beverages), and E860.1(Accidental Poisoning by Ethyl Alcohol). The differences between the NIAAA rates and the present authors' explicit-mention rates were the use of multiple-cause versus underlying cause data and the combination of N and E codes for poisoning. Whereas the present authors use specific combinations of codes, the description of the methods used in the NIAAA rates suggests that any case with a relevant code was included.

The OAS publishes annual DAWN Medical Examiner (ME) reports (OAS 1998, 2000a). These reports contain data submitted by medical examiners in metropolitan areas nationwide. The medical examiners report on the incidence of drug use among decedents. A "consistent panel" of examiners who report most consistently is employed to facilitate comparisons among different years. That is, the data are compiled from the same group of medical examiners in order to discern differences among years. This chapter drew on two such consistent panels; one from 1993-96 and the other from 1996-99. The former had 138 medical examiners, and the latter 134 (OAS 1998, 2000a). When rounded to one decimal and graphed, these separate lines appear to form a single continuous line.

For purely methodological purposes, the authors included these ME statistics because of the assumed accuracy of drug-related diagnoses in medical examiner data when compared to mortality statistics for all deaths, which have been questioned by some authors (see McAuliffe et al. 2001 for a review). In order to compare the trends in the ME data to the other drug mortality rates, the authors created rates per 100,000 using total US population estimates from the Census Bureau (2000). The authors assumed that the population changes over time in the DAWN areas would closely reflect changes in the national population. Because the DAWN data reflect urban populations rather than the total national population, readers should not interpret the absolute level of the rates as estimates of the national mortality rates.

Treatment Client Rates

With the exception of 1994, the OAS (1995a,b, 1996a, 1997b,c, 1999b, 2000g) has conducted an annual survey of treatment facilities to assess the number of persons in specialty substance abuse treatment at one point in time. The study has been known by two names over the relevant years: NDATUS from 1987 to 1994 and the UFDS thereafter. The survey was not conducted in 1994; instead the values for that year were estimates from an econometric model incorporating prior years, changes in state treatment funding levels, unemployment, population changes, and changes in food stamp costs (OAS 1996a). In the years used in this chapter (1992-1998), the sampling frame was a listing called the National Facility Register that OAS updates continuously. The total number of facilities ranged from 11,316 in 1992 to 19,174 in 1998. The facilities included specialty providers of substance abuse treatment, including public and private free-standing units and units in multi-purpose institutions. The facilities were owned by private for-profit and non-profits, as well as federal, state, local, and tribal governments. The federal facilities included the Veterans Administration, Defense Department, Bureau of Prisons, and the Indian Health Service. Identified mostly by state and federal agencies, these providers completed a questionnaire about all active clients in treatment on a specific reference day in the previous year (e.g., September 30, 1992, and October 1 or in the first week in October in 1993 to 1998).

The NDATUS/UFDS clients are categorized into three groups: Alcohol only (35% nationally), alcohol and drugs (40%), and drug only (25%) in 1991-1993. On the basis of theoretical and empirical analysis, the authors selected the drug-only and alcohol-only clients as measures rather than the combined drug-only plus drug-and-alcohol-treatment clients or the combined alcohol-only plus drug-and-alcohol treatment clients. Of course, the primary reason for not including the drug-and-alcohol treatment clients in both measures was to avoid counting the same clients in both measures, and the authors believed that the selected measures would be more valid indicators of the supply of the two different types of services. The authors' review of NDATUS/UFDS statistics revealed that providers in many states (especially Massachusetts, Alaska, New Hampshire, Nebraska and Texas) were more likely to utilize the drug-and-alcohol-treatment clients measure than the drug-only measure, but providers in other states (Alabama, Arizona, New Mexico, New York, Rhode Island, and California) were more likely to use the drug-only category. Years of clinical experience working in several of these states caused us to hypothesize that many of the clients in the drug-and-alcohol category may have had alcohol use disorders but were only users of illicit drugs rather than persons who met standard criteria for drug abuse or dependence. Although NDATUS/UFDS defines this category adequately in the glossary that accompanies its survey questionnaire, even experts sometimes use the term "drug abuse" to refer to the use of illicit drugs, whereas they reserve the terms "alcohol abuse" for excessive use that results in symptoms and is likely to require treatment (see McAuliffe et al. 1999).

The empirical behavior of the drug-only client measure and the combined client measure for 1991-1993 data mostly supported the authors' hypothesis. Although the two measures correlated substantially with each other (.79, p<.05), the correlation of drug arrest rates with drug-only client rates (.63) was significantly greater than the correlation of drug arrest rates with the combined client rates (.42). Drug mortality rates correlated significantly more with the drug-only client rate (.89) than with the combined client rates (.70), and IV-AIDS statistics correlated significantly more with the drug-only client rate than with the combined client rate (.76 versus .57). The drug-only client rate correlated slightly more strongly with NHSDA model estimates of past year drug treatment than did the combined measure (.28 versus .23), but the difference was not significant. The drug-only client rates correlated significantly less than the combined client measure with National Association of State Alcohol and Drug Abuse Directors (NASADAD) drug-related admissions (.47 versus .62).

Treatment Admission Rates

The OAS collects administrative data on treatment admissions from all states. The data include admissions from only those programs that are licensed by the state substance abuse agency and required to report data to it. Inclusion of private, hospital, and prison treatment varies from state to state depending on the state substance abuse agency's licensing and reporting regulations. Mostly, the admissions represent admissions to publicly-funded treatment. OAS publishes reports called the Treatment Episode Data Set (TEDS)using those data (OAS and Synectics for Management Decisions, Inc., 2000e). The report includes rates per 100,000 in the total population that are involved in substance abuse treatment at a facility of the type described above. Because the data are published on an admissions rather than a client basis, an individual may be counted more than once if he/she was admitted for treatment more than once within the same year. Rates are reported for total admissions as well as for specific categories of substances (such as alcohol, cocaine, marijuana or hashish, etc.).

Survey-Reported Treatment

The NHSDA (OAS 1996b, 1997a, 1999a, 2000c, d, f) rep