Treatment Services, 1980-1992

The NDATUS survey asks treatment providers to report a 1-day census of clients for 8 different types of treatment. National totals for these 8 categories are presented in Appendix 7, Table 9. However, from the viewpoints of cost and services received by clients, 3 treatment categories are critical -- 1) 24-hour detoxification, 2) 24-hour rehabilitation, and 3) outpatient. A fourth category -- outpatient methadone treatment -- is distinguished as a subset of outpatient services because it involves the prescription of a regulated narcotic as an oral substitute for heroin.

• Across the nation in 1992, 87% of daily clients were enrolled in outpatient rehabilitation, including 75% in drug free and 12% in methadone programs. The remaining 13% were in 24-hour treatment, including 11% in rehabilitation and 2% in detoxification.

• The proportion of outpatient rehabilitation clients increased slowly but steadily during the 12 years between 1980 and 1992. The proportion of outpatient methadone clients went up, down, and then up again, but it stayed between 12% and 15% of all clients.

Clients in Specialty Substance Abuse Treatment by Treatment Category

                                       Percent
                       1980   1982   1987   1989   1991   1992

Outpatient 
  Drug-Free Rehab.     70.3   68.3   72.3   73.1   75.6   74.8
Outpatient Methadone
  Rehab.               13.8   15.4   13.3   12.6   12.2   12.3
Rehabilitation
  (24-hr care)         13.3   13.4   12.0   12.0   10.8   11.3
Detoxification
  (24-hr care)          2.7    2.9    2.5    2.2    1.4    1.6

• In 1992, the proportion of clients in 24-hour detoxification was less than 6% in all States, and 3% or less in 40 States. However, States varied widely in their proportion of clients in outpatient versus 24-hour rehabilitation, and in their proportion of outpatient methadone clients.

• Minnesota (32%) had the highest proportion of clients in 24-hour rehabilitation, followed by Mississippi (31%), and Arkansas and New Hampshire (26%). Kentucky and Rhode Island had the highest proportion of clients in outpatient rehabilitation (94%), followed by Colorado, Maryland, Michigan, New Mexico, and Oregon (93%).

• New York (32%) had the highest proportion of clients in outpatient methadone treatment, followed by Arizona (31%), New Jersey (27%) Connecticut and Nevada (25%). Ten States reported no methadone clients.

• When the States are ranked by number of clients per 100,000 in the general population age 12 and above, there appears to be a positive correlation between clients per 100,000 and the proportion of clients in outpatient treatment. In other words, the higher the rate of clients in treatment, the greater the proportion of clients in outpatient care. A partial explanation for this is that outpatient care typically costs less per day than 24-hour care, so the same funding can support more outpatient clients on a given day.

See Table 6B in Appendix 7 for data.

The predominance of outpatient over 24-hour rehabilitation has two major caveats. First, it is much more difficult for providers to accurately count the number of outpatient clients because the definition is more complicated, many more records must be reviewed, and because many "actively enrolled" clients, who had scheduled appointments during past month, may in fact never return. As a result, many respondents may estimate their active outpatient clients without any detailed review of clinical records.

Second, because 24-hour programs typically have shorter lengths-of-stay, more clients are admitted to (or cycle through) 24-hour slots than outpatient slots during a year. Consequently, the proportion of 24-hour clients measured on this one-day census is lower than it would be if clients were reported as an annual flow.

See Table 6B for data and Table 3 for rankings in Appendix 7.

Matching Clients to Treatment

For each type of treatment, the survey enumerates the number of clients with alcohol-only, drug-only, and both problems. Although these three types of substance abuse have only limited value in classifying problem severity, clients with both problems are likely to have more severe dependency problems.

• Clients with both alcohol and drug problems receive the most intensive treatment. In 1992, 20% of clients with both problems were in 24-hour treatment versus 10% for drug-only and 8% for alcohol-only. In 1991, 19% of clients with both problems were in 24-hour treatment versus 12% for drug-only and 8% for alcohol-only.

Clients by Treatment Category and Substance Abused

*********************************************
                                       Number
*********************************************
                          Drug    Alcohol             All
                          Only      Only     Both    Clients*
-------------------------------------------------------------

1992
All Clients             237,004   348,677   359,198   944,880
Detoxification
   (24-hr care)           2,585     5,107     7,219    14,912
Rehabilitation 
   (24-hr care)          20,989    21,554    64,483   107,026
Outpatient              213,429   322,016   287,495   822,941

1991
All Clients             237,008   365,147   209,664   811,819
Detoxification
   (24-hr care)           2,476     5,158     3,838    11,472
Rehabilitation
   (24-hr care)          26,224    24,672    36,782    87,678
Outpatient              208,308   335,317   169,044   712,669

*****************************************************
                                       % by Substance
*****************************************************

1992
All Clients                25.1     36.9       38.0     100.0
Detoxification
   (24-hr care)            17.3     34.2       48.4     100.0
Rehabilitation 
   (24-hr care)            19.6     20.1       60.3     100.0
Outpatient                 25.9     39.1       34.9     100.0

1991
All Clients                29.2     45.0       25.8     100.0
Detoxification
   (24-hr care)            21.6     45.0       33.5     100.0
Rehabilitation
   (24-hr care)            29.9     28.1       42.0     100.0
Outpatient                 29.2     47.1       23.7     100.0

**********************************************************
                                       % by Treatment Type
**********************************************************

1992
All Clients               100.0    100.0      100.0     100.0
Detoxification
   (24-hr care)            1.1       1.5        2.0       1.6
Rehabilitation 
   (24-hr care)             8.9      6.2       18.0      11.3
Outpatient                 90.1     92.4       80.0      87.1

1991
All Clients               100.0    100.0      100.0     100.0
Detoxification
   (24-hr care)             1.0      1.4        1.8       1.4
Rehabilitation
   (24-hr care)            11.1      6.8       17.5      10.8
Outpatient                 87.9     91.8       80.6      87.8

*The large difference between 1992 and 1991, in total clients, may be entirely because clients treated by non-responding providers were only estimated in 1992.

• In Figure 15, the overall proportions of clients by substance problem are compared to their proportions within each treatment category. If clients were randomly distributed across all treatment categories, then in each substance problem group all bars would be about the same height. Note the bars are uneven in both years, and that they are more uneven in 1992.

There are two possible reasons why clients with poly-substance abuse are more often treated in 24-hour programs. They may be more disabled by their substance abuse--and thus require round-the-clock care--or they may need to be taken out of environments that perpetuate substance abuse.

The large increase from 1991 to 1992 in the proportion of clients reported with both problems is something to watch over time. It may indicate that clients presenting for treatment have more serious problems. It also may reflect the fact that providers are still getting used to this 3-part scheme for classification of clients (drug-only, alcohol-only, and both). It was introduced in 1990, and 1991 was the first year when reliable data were reported.

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