Attachments 4-10

Attachment 4: List of Secondary Data Sets

1

•

Census 2000 Datasets

The Decennial Census occurs every 10 years, in years ending in zero, to count the population
and housing units for the entire United States. Its primary purpose is to provide the
population counts that determine how seats in the U.S. House of Representatives are
apportioned. Besides providing the basis for congressional redistricting, Census data are used
in many other ways. Since 1975, the Census Bureau has had responsibility to produce smallarea population data needed to redraw state legislative and congressional districts. Other
important uses of Census data include the distribution of funds for government programs
such as Medicaid; planning the right locations for schools, roads, and other public facilities;
helping real estate agents and potential residents learn about a neighborhood; and identifying
trends over time that can help predict future needs. Most Census data are available for many
levels of geography, including states, counties, cities and towns, ZIP codes, census tracts and
blocks, and much more.
http://factfinder.census.gov/jsp/saff/SAFFInfo.jsp?geo_id=01000US&_geoContext=01000U
S&_street=&_county=&_cityTown=&_state=&_zip=&_pageId=sp4_decennial&_submenuI
d=&_ci_nbr=null

•

NSSATS
The National Survey of Substance Abuse Treatment Services (N-SSATS) is designed to
collect information from all facilities in the United States, both public and private, that
provide substance abuse treatment. N-SSATS provides the mechanism for quantifying
the dynamic character and composition of the United States substance abuse treatment
delivery system. The objectives of N-SSATS are to collect multipurpose data that can be
used to assist the Substance Abuse and Mental Health Services Administration
(SAMHSA) and state and local governments in assessing the nature and extent of
services provided and in forecasting treatment resource requirements, to update
SAMHSA's Inventory of Substance Abuse Treatment Services (I-SATS), to analyze
general treatment services trends, and to generate the National Directory of Drug and
Alcohol Abuse Treatment Programs and its online equivalent, the Substance Abuse
Treatment Facility Locator. Data are collected on topics including ownership, services
offered (assessment and pre-treatment, pharmacotherapies, testing, transitional,
ancillary), detoxification, primary focus (substance abuse, mental health, both, general
health, and other), hotline operation, methadone/buprenorphine dispensing, counseling
and therapeutic approaches, languages in which treatment is provided, type of treatment
provided, number of clients (total and under age 18), number of beds, types of payment
accepted, sliding fee scale, special programs offered, facility accreditation and
licensure/certification, and managed care agreements.
http://www.icpsr.umich.edu/icpsrweb/SAMHDA/studies/26221/detail
2

•

SAMSHA Treatment Gap Projection Analysis
National Survey on Drug Use and Health (NSDUH), an annual survey of the civilian, is
the primary source of statistical information on the use of illegal drugs by the U.S.
population. Conducted by the Federal Government since 1971, the survey collects data by
administering questionnaires to a representative sample of the population through face-toface interviews at the respondent's place of residence. The survey is sponsored by the
Substance Abuse and Mental Health Services Administration (SAMHSA), U.S.
Department of Health and Human Services, and is planned and managed by SAMHSA's
Office of Applied Studies (OAS). Data collection and analysis are conducted under
contract with RTI International, Research Triangle Park, North Carolina.
http://www.oas.samhsa.gov/NSDUH/2k7NSDUH/2k7results.cfm#1.1

•

Treatment Episode Data
The Treatment Episode Data Set (TEDS) is an administrative data system providing
descriptive information about the national flow of admissions to providers of substance
abuse treatment. The TEDS is a continuation of the former Client Data System (CDS)
that was originally developed by the Alcohol, Drug Abuse, and Mental Health Services
Administration (predecessor to SAMHSA) in consultation with representatives of the
state substance abuse agencies and appropriate national organizations.
http://www.icpsr.umich.edu/icpsrweb/SAMHDA/series/56#summary

•

Bureau of Labor datasets such as Current Employment Statistics
The Bureau of Labor Statistics (BLS) is a unit of the United States Department of Labor.
It is the principal fact-finding agency for the U.S. government in the broad field of labor
economics and statistics. The BLS is a governmental statistical agency that collects,
processes, analyzes, and disseminates essential statistical data to the American public, the
U.S. Congress, other Federal agencies, State and local governments, business, and labor
representatives. The BLS also serves as a statistical resource to the Department of Labor.
The BLS data must satisfy a number of criteria, including relevance to current social and
economic issues, timeliness in reflecting today’s rapidly changing economic conditions,
accuracy and consistently high statistical quality, and impartiality in both subject matter
and presentation. To avoid the appearance of partiality, the dates of major data releases
are scheduled more than a year in advance, in coordination with the Office of
Management and Budget.
3

http://www.bls.gov/data/
•

Annapolis Coalition Data

The Annapolis Coalition, comprised of a broad constituency of stakeholders, was charged by
SAMHSA to develop a comprehensive plan addressing the workforce development crisis and
issues surrounding recruitment, retention, and training of a prevention and treatment
workforce in the mental health and addiction field.
The final plan, An Action Plan for Behavioral Health Workforce Development, reviews the
current workforce and its environment; outlines a set of general findings; identifies seven
core strategic goals; and outlines the objectives and actions necessary to achieve each
goal. Now the Coalition is launching a major initiative to disseminate the Action Plan and
promote the adoption and adaptation of the recommendations by individuals, organizations,
and government agencies across all sectors of this field
http://attcnetwork.org/find/respubs/docs/WorkforceActionPlan.pdf

4

Attachment 5: List of ATTC Network Regional Centers

1

2

3

Attachment 6: ATTC Literature review: Understanding America’s
Substance Use Disorders Treatment Workforce: A Summary Report

1

Understanding America’s Substance
Use Disorders Treatment Workforce: A
Summary Report

Prepared for:
Addiction Technology Transfer Center (ATTC) National Office

Prepared by:
Deena M. Murphy and Robert L. Hubbard Institute for Community‐Based Research, National
Development and Research Institutes, Inc.

2

This report was produced by the Addiction Technology Transfer
Center (ATTC) National Office with support from a grant (#
TI‐013592) from the Substance Abuse and Mental Health Services
Administration (SAMHSA) Center for Substance Abuse Treatment (CSAT). All material
appearing in this publication except that taken directly from copyrighted sources is in the
public domain and may be reproduced or copied without permission from SAMHSA/CSAT or
the authors. Citation of the source is appreciated. Do not reproduce or distribute this
publication for a fee without specific, written authorization from the ATTC National Office. For
more information on obtaining copies of this publication, call 816‐235‐6888.
At the time of publication, Eric Broderick, DDS, MPH, served as the Acting SAMHSA
Administrator. H. Westley Clark, MD, JD, MPH, served as CSAT Director; Jack B. Stein, LCSW,
PhD, served as Director of CSAT’s Division of Services Improvement; and Catherine D. Nugent,
LCPC, served as the CSAT Project Officer.
The opinions expressed herein are the views of the authors and do not necessarily reflect the
official position of CSAT, SAMHSA, or DHHS. No official support of or endorsement by CSAT,
SAMHSA, or DHHS for these opinions or for particular instruments, software, or resources
described in this document is intended or should be inferred. The guidelines in this document
should not be considered substitutes for individualized client care and treatment decisions.

3

Acknowledgements
This report is the first task of a subcontract from the Addiction Technology Transfer Center
(ATTC) National Office, funded by the Substance Abuse & Mental Health Administration’s
(SAMHSA) Center for Substance Abuse Treatment (CSAT), to the Institute for
Community‐Based Research, National Development and Research Institutes, Inc. (NDRI). The
next step will be a set of targeted stakeholder discussions, followed by the development of a
national survey instrument that will aid in the systematic collection of data on the substance use
disorders treatment workforce. Robert Hubbard, Director of the Institute for Community ‐Based
Research, and Deena Murphy, Principal Research Associate, were the lead staff on this project.
Prior to the writing of the report, a panel of experts in the substance use disorders treatment
field met in April, 2008 at the SAMHSA Building in Rockville, MD. The expert panel offered
insight and wisdom on how to move the National Survey forward. Their suggestions helped
spark the idea for the development of this report. The members of the expert panel were as
follows:
Dr. Anthony Floyd, University of Washington/Alcohol & Drug Abuse Institute Dr. Thomas
Hilton, National Institute on Drug Abuse Dr. Robert Hubbard, National Development &
Research Institutes, Inc. Deann Jepson, ATTC National Office Mary Beth Johnson, ATTC
National Office Dr. Hannah Knudsen, University of Kentucky Laurie Krom, ATTC National
Office Cathy Nugent, Center for Substance Abuse Treatment Nancy Roget, Mountain West
ATTC Dr. Michael Shafer, Pacific Southwest ATTC Dr. Anne Helene Skinstad, Prairielands
ATTC Flo Stein, Department of Health and Human Services Dr. Jack Stein, Center for Substance
Abuse Treatment
Aaron Williams, Central East ATTC
In addition, Dr. Robert Atanda, Center for Substance Abuse Treatment, facilitated the meeting.

4

Introduction
Purpose of report
The purpose of this summary report is to gain a current perspective on the substance use
disorders treatment field’s workforce. This report will identify key resources which provide
information relevant to three strategic research questions:
1
What are the basic demographics of the workforce?
2
What are the anticipated workforce development needs for 2010‐2015?
3
What are the common strategies & methodologies to prepare, retain and maintain the
workforce?
A review of these key resources should highlight gaps in current knowledge related to the three
research questions in order to inform the agenda and content of the targeted stakeholder
discussions in addition to aiding the development of the survey instrument. Consequently the
review is focused primarily on those issues that affect decisions on the content of the proposed
director survey.

Methodology
This report utilized all the workforce materials from a variety of sources with a focus on 20032008. This included surveys and reports from the Addiction Technology Transfer Center
(ATTC) Network in addition to government‐funded reports, studies, and white papers from
myriad professional groups and coalitions.
A recent literature review (2003 ‐2008) relevant to workforce issues in the substance use
disorders treatment field was also conducted. Initially, this included a computerized
bibliographic search of databases including EBSCO, LexisNexis Academic, MEDLINE, Web of
Science (Social Sciences Citation Index), PubMed and PsycINFO.
While the workforce literature is clearly growing due to a renewed focus by SAMHSA/CSAT,
there is still a dearth of standardized studies on substance use disorders treatment agencies.
The workforce materials currently in existence demonstrate inconsistent methodologies, poor
response rates, and lack the scope necessary to draw conclusions and/or comparisons.
Consequently, this report will make every attempt to reflect the current information available
with the caveat that this information has limitations which should be addressed in future
workforce studies.

Report layout

5

Based on a review of the literature and feedback from the ATTC
National Office, this report is divided into three sub‐sections
relevant to the three key research questions. Each sub
‐section will
emphasize the findings (what is known), the limitations (gaps in
our current knowledge), and recommendations or issues for further discussion.

6

What are the basic demographics of the workforce?
What is known?
The substance use disorders workforce is diverse in discipline and setting
There is great variation in the numbers of substance use disorders treatment staff. Conservative
data estimates suggest that the substance use disorders treatment workforce is comprised of
more than 67,000 individuals from myriad disciplines including health, criminal justice,
substance use disorders treatment, mental health, social services, and recovery support
advocates (Harwood, 2002). Data presented by Dr. H. Westley Clark at the Northeast ATTC
Summit on workforce development revealed that the substance use disorders treatment
workforce is comprised of 135,000 full ‐time employees, 45,000 part‐time employees, and 22,000
contract employees (Northeast ATTC, 2004). According to the 2003 Center for Substance Abuse
Treatment (CSAT) Environmental Scan, the substance use disorders treatment workforce was
estimated at 135,000 full ‐time staff; 45,000 part‐time staff; and 22,300 contracted staff. Seventeen
percent of medical staff at substance use disorders treatment facilities worked full time, 31%
part time, and 47% contracted (the status of 5% was unknown). In 2003, 47% of
administrative/nonclinical substance use disorders staff were full time, 43% part time, and 10%
contracted. These individuals work in a variety of settings including outpatient, residential,
medical, detoxification, correctional, and a variety of specialty service and community settings.
The workforce is older, white, and predominantly female
Data from an environmental scan conducted by Kaplan (2003) describes the substance use
disorders workforce as averaging 45 ‐50 years old, 70‐90 percent non‐Hispanic whites, and over
50 percent female. A 2003 CSAT study (Mulvey, Hubbard, & Hayashi, 2003) surveyed 3,267
Single State Agency (SSA) Directors, facility directors, clinical supervisors, and program
counselors and found that most of the substance use disorders workforce are white (85%), 40 ‐55
years old (60%), and slightly more are female (50.5%). Two studies focused on one region
(Northwest) or one state (Kentucky) found differences between management and direct service
staff, with directors being more frequently male, but more information is needed nationally to
obtain an accurate picture (RMC 2003a; RMC 2003b).
The workforce demographics do not reflect the treatment population
The majority of treatment professionals are white, female, and 45‐50 years old. These workforce
demographics are in contrast to the treatment population, who are predominantly between the
ages of 25‐44, are 60 percent non‐Hispanic whites, and over 70 percent male (TEDS, 2007).
The workforce is well‐educated, but exact data is unclear
There are significant variations in the reported education levels of the workforce. What is
agreed upon is that most substance use disorders programs do not have full ‐time staff with
medical degrees or other advanced graduate degrees.
7

Previous research indicated that 60 to 80% of direct ‐service staff
have at least a bachelor ʹs degree, and almost 50% have a masterʹs
degree. Multiple studies support that approximately 80 percent of
the workforce hold a bachelor’s degree (Johnson et al., 2002;
Knudsen et al., 2003; Mulvey et al., 2003; RMC 2003a). In contrast, two ATTC Regional Centers,
the ATTC of New England and the Northwest Frontier ATTC, reported only 60 percent of staff
having bachelor’s degrees (ATTC of New England; RMC 2003a; Gallon et al., 2003). In terms of
graduate degrees, Harwood (2002) reports that 53 percent of direct service staff holds master’s
degrees, Gallon et al. (2003) finds 57 percent of directors have graduate degrees, and Mulvey et
al. (2003) found that 49 percent of staff possessed master’s degrees, and 7.4 percent held
doctoral degrees.
The 2003 Center for Substance Abuse Treatment Environmental Scan (Kaplan, 2003),
disaggregates this into full ‐time and part‐time staff. Among the overall staff, 17% of full‐time
staff, 17% of part ‐time staff, and 32% of contracted staff had graduate degrees. Among the
administrative/nonclinical staff, 68% had bachelor ʹs degrees and 77% had masterʹs degrees.
Twenty‐nine percent of full‐time staff had bachelorʹs degrees or no degrees, 22% of part‐time
staff, and 11% of contracted staff.
The CSAT scan found that most academic education occurred at the community college level,
with course and program quality highly variable. No accreditation standards exist for training
in the substance use disorders field. Most training was didactic with little to no management or
leadership development programs available. Whereas most staff (90%) attends training
annually, little is known about the quality of in ‐service education, clinical supervision,or
academic courses in substance use disorders
Turnover rates are high, but professionals seem to stay in the substance use disorders field
In terms of retention of substance use disorders treatment staff, Harwood (2002) notes that 70
percent of substance use disorders professionals have worked with their current employer for
five years or less. Mulvey et al. (2003) found that 62 percent of the substance use disorders
treatment professionals had worked in the field for more than 10 years, but that 51 percent had
worked in their current position for less than five years. McLellan, Carise, & Kleber (2003)
found that 54 percent of treatment program directors had been in their position for less than one
year and estimated the counselor turnover rate at 50 percent. In contrast, research using the
University of Georgia National Treatment Center Study data indicates an average turnover rate
of 18.5 percent among counselors (Knudsen, Johnson, & Roman, 2003) and 25 percent across all
staff at substance use disorders agencies (Gallon, Gabriel, & Knudsen, 2003). While varying
from 20‐50 percent, this rate is significantly higher than the national average of 11 percent
across all occupations and exceeds the annual turnover rates for both teachers (13%) and nurses
(12%), occupations traditionally known to have high turnover rates (Knudsen et al., 2003; US
DHHS, 2007).

8

Salaries for substance use disorders professionals are low and impact
retention rates
Studies of substance use disorders treatment professionals’ income indicate that median salaries
for substance use disorders staff are low and that increasing salary is a prevalent
recommendation for retaining staff (Knudsen & Gabriel, 2003; U.S. Department of Labor, 2000).
According to statistics from the U.S. Department of Labor in 2000, the median income for
addictions treatment counselors was $28,510 and the mean income was $30,100. A survey of
counselors further found that 30 percent had no medical coverage, 40 percent had no dental
coverage, and 55 percent were not covered for substance use or mental health services (Galfano,
2004; US DHHS, 2007).
In the CSAT scan (Kaplan, 2003), average starting salaries in the substance use disorders field
are in the low $30,000s. The majority of new counselorsʹ salaries range from $15,000 to $34,000.
The majority of agency directors ʹsalaries range from $40,000 to $75,000. Higher salaries are
associated with having a graduate degree.
In a number of studies that looked at retention, a major factor contributing to retention
problems was low salary (RMC 2003a; RMC 2003a; Gallon et al 2003; Lewin ‐VHI 1994;
NAADAC 2003; Knudsen, Johnson & Roman 2003). In focus groups conducted throughout New
York State, salary was identified by the eleven workforce development focus groups as the
single most important issue for staff recruitment and retention (OASAS, 2002).

Limitations of current data available: Further questions
How accurately do the findings reflect the state of the field?
As the workforce survey study table shows (Appendix), there is significant variability and
major discrepancies in the response rates for various surveys. If those programs and staff more
likely to respond surveys are not representative of the true population, the demographic
statements may be misleading. A further concern is the lack of data that differentiates key
differences in treatment modalities, urban versus rural areas and key organizational
characteristics such as community based versus national, private versus public and fee for
service versus case rate reimbursement. It would appear likely that many of the demographic
results may vary greatly across these key domains.
How does turnover in an agency correlate with turnover in the field?
While we understand that there is a high turnover among substance use disorders
professionals, it is unclear whether they are leaving the field or simply transferring between
agencies to secure better positions, salaries, professional development opportunities, or benefits.
A report by Light (2003) suggested that 28 percent of the workforce report that their
best‐qualified co‐workers leave within two years or less. What is unknown is whether they are
drawn to substance use disorders agencies with better professional development opportunities
or better benefits packages or are leaving the field entirely.
9

How do turnover rates differ by age and what are the implications of this?
One area to pay particular attention to are the turnover rates by
age category, especially given the “graying” of the substance use
disorders treatment workforce. An Annie E. Casey Foundation
report (2002) found that 30 percent of 18‐35 year olds working in the human services field five
years or less planned to leave within two years. This implies there is a national need to
address or understand the reasons why younger staff may be leaving the workforce.

Recommendations
Standardize organizational definitions and improve response rates
Future survey research needs to ensure a standardized framework is provided for identifying
organizations and ensuring response rates are adequate to provide empirical support for any
findings. Some of the earlier ATTC surveys have had response rates of 17% (Florida, 2004),
while others ranged upwards to 94% (Puerto Rico, 2002), and others did not disclose response
rates (see the Appendix for brief information about the workforce surveys). Obtaining a
representative sample of substance use disorders treatment organizations across the U.S. is
essential if we are to present a complete and accurate picture of the substance use disorders
treatment workforce. One issue which could be raised in the focus groups could revolve around
the appropriate survey length. What is a reasonable amount of time to expect a substance use
disorder treatment organization director to spend completing this survey? The previous survey
was 25 pages and it would be important to assess whether this factor impacted response rates.
Include standardized individual and organizational demographics in addition to retention indicators
Demographic questions should include sex, race/ethnicity, organizational role, years of
experience, years with current organization, education level, formal education in substance use
disorders (certification), percentage in recovery, and certification with accredited board. Salary,
work satisfaction, and intention to remain in the field could be included as indicators of
retention. It is also critical to develop these demographic indicators in ways that provide
practical administrative utility. We think estimates should be presented at a minimum by
treatment modality, by geographic location (such as urban/rural), and major organizational
characteristics (such as size). Including these distinctions (treatment modality, geographic
location, and major organizational characteristics) will allow the ATTC Network to identify
differential impacts of such issues as staff turnover, workforce aging, and salaries.

10

What are the anticipated workforce development
needs for 2010‐2015?
What is known?
There is insufficient treatment capacity or workforce to meet current and future demands
Data presented at the Northeast ATTC Summit on workforce development (Northeast ATTC,
2004) suggested that the mental and behavioral health workforce needs will increase by 27
percent by 2010 with 5,000 new counselors needed annually to compensate for net replacement
and growth. A 2003 report by NASADAD indicates that by 2010 there will be a 35 percent
increase in the need for addictions professions and licensed treatment staff with graduate‐level
degrees. Statistics from the Bureau of Labor estimate that there will be 3,000 unfilled positions
for addictions counselors by 2010 (Landis et al., 2002). Demographic changes, especially in
relation to the aging of the current workforce, suggest that this staffing shortage will worsen
from 2010 to 2015.
Myriad trends will impact future recruitment and retention of the workforce
Key trends impacting the workforce identified by the U.S. DHHS report to Congress (2007)
include:
•
Insufficient workforce/treatment capacity to meet demand;
•
The changing profile of those needing services;
•
A shift to increased public financing of treatment;
•
Challenges related to the adoption of best practices;
•
Increased utilization of medications in treatment;
•
A movement toward a recovery management model of care;
•
Provision of services in generalist and medical settings;
•
Use of performance and patient outcome measures; and
•
Discrimination associated with addictions.
Individuals entering treatment are increasingly presenting more complex and severe substance
use disorders (and mental health) issues. The National Survey of Substance Abuse Treatment
Services (N‐SSATS, 2004) data shows an increasing number of injecting drug users, narcotic
prescription, and methamphetamine users. From 1991 to 2001, private insurance declined from
24 to 13 percent of substance use disorders expenditure (Mark et al., 2005). Private health plan
coverage for substance use disorders treatment continues to decline in terms of fixed dollars
and as a percentage of the overall health plan coverage, resulting in increased burdens on
publicly funded treatment systems. Consequently, clinicians and programs are dealing with a
more severely impaired population, being referred earlier in the progression of their disorder,
with less financial compensation. Addressing these challenges and the key trends outlined by
the DHHS requires a workforce with a more diverse skill set at the executive, management, and
practitioner levels. This further emphasizes the need for stronger alliances between substance
use disorders and other allied professionals to ensure there is sufficient experience in areas such
11

as brief treatment, medication assisted therapies, and co‐occurring disorders.

12

Limitations of current data available: Further questions
What are annual staff turnover rates and staffing needs?
It is clear that substance use disorders treatment programs are struggling with recruiting and
retaining staff, but we have limited insights into turnover rates within each substance use
disorder treatment organization. If we had access to previous year’s turnover rates, it would
allow the ATTC Network to look closer at the organizational factors that may be impacting
annual turnover. In addition, it is critical to understand how many staff members are needed or
how many staff positions are currently vacant within each organization. Data could then be
aggregated by modality, by urban/rural, and major organizational characteristics to assess if
these factors impact turnover and recruitment needs.
How are client demographics changing?
The N‐SSATS (2004) and DHHS (2007) data and reports show that client demographics are
changing and more complex and severe substance use disorder and mental health issues are
being presented. What is not known is how these demographics differ by treatment modality
or by geographic location. If it is critical for more severe clients to be engaged in a network of
allied professionals, are there differences in urban and rural responses to this based on the
existing program infrastructure and resources?
What is the relationship between education, training, and treatment outcomes?
The current research provides some descriptive demographic information surrounding the
education and training of substance use disorders treatment staff, but previous workforce
surveys have included no data on treatment outcomes. Depending on modality, treatment
outcomes data could include items such as percentage of clients retained in treatment over 90
days or percentage completing treatment. While there is some research that suggests there is a
relationship between higher levels of education and increased turnover, it is unclear whether
this impacts treatment outcomes.

Recommendations
Include annual turnover rates and current staffing needs
To ensure the ATTC Network can assess what factors are impacting turnover and recruitment
issues, it will be critical to have an accurate assessment of annual turnover rates and staffing
needs within each organization. The Director’s survey should include items related to previous
year’s turnover in addition to current staffing needs and open positions. This will allow the
national study to disaggregate data by treatment modality, by geographic location
(rural/urban), or by other major organizational factors (such as size) to determine whether there
are specific staffing issues related to these groupings. This will provide baseline data to help
plan future interventions related to recruitment and retention.

13

Include questions related to changing client demographics
To understand how client demographics are changing, any
interviews or focus groups conducted should also ensure that
open‐ended questions related to client treatment needs are included to assess the need to
include them in the future survey. It would be useful to assess whether there are regional as
well as urban/rural differences in client demographics and how this relates to provision of
services in addition to utilization of medications.
Assess the possibility of including treatment outcomes
While treatment outcomes will differ in definition across various treatment modalities, focus
groups and interviews could assess the potential of including some treatment outcome items in
the survey. For outpatient programs, this could include the percentage of clients retained in
treatment. For short‐term residential, this could include the percentage of clients completing
treatment. These treatment outcome measures will be useful in allowing the ATTC Network to
look at the impact of factors such as staff turnover, organizational characteristics, and client
demographics.

14

What are the common strategies & methodologies
to prepare, retain and maintain the workforce?
What is known?
There is a general national consensus around workforce development recommendations
Recommendations for preparing, retaining and maintaining the workforce come from three
main sources: the SAMHSA/CSAT 2006 Strengthening Professional Identity report (Abt
Associates, 2006), the 2003 CSAT Workforce Environmental Scan (Kaplan, 2003), and the 2007
Annapolis Coalition deliberations. The Strengthening Professional Identity Report was built
upon the Environmental Scan Report (Kaplan, 2003) and involves a set of recommendations
developed through nine stakeholder meetings involving 128 individuals. SAMHSA and the
Annapolis Coalition facilitated a strategic planning process with eighteen national experts to
develop “An Action Plan for Behavioral Health Workforce Development,” which included a set
of recommendations specific to substance use disorders treatment that incorporated strategies
related to preparing, retaining, and maintaining the workforce (Annapolis Coalition, 2007).
While there are differences between each report, there is an overall consensus around
recommendations for workforce development, but limited specifics on strategies and
methodologies to prepare, recruit, retain, and professionally maintain the substance use
disorders treatment workforce. Strategies and methodologies that are referenced include those
relevant to professional development, infrastructure development, leadership and management
practices, recruitment and retention processes, and an improved research and evaluation focus.
Professional development strategies are key to retaining and maintaining a strong workforce
All three reports emphasized that professional development strategies are key to retaining and
maintaining a strong workforce. One key focus highlighted in the Annapolis
Coalition/SAMHSA report was the importance of expanding peer recovery support services to meet
increasing education and credentialing requirements. More than 50 percent of people providing
direct treatment services are in recovery (CSAT National Treatment Plan Initiative, DHHS
2000). Recent and ongoing changes in education and credentialing requirements are creating
challenges to maintain the role of people in recovery in the behavioral health workforce. In
addition, there is limited evaluation of peer recovery support services to assess the most
effective approaches. Consequently, one important strategy is to ensure there is a professional
development system in place to retain the peer recovery system and increase the effectiveness
of these peer recovery support service programs.
There is a need to develop infrastructure around substance use disorder treatment
Improving infrastructure development around substance use disorders led to a number of
different recommendations. CSAT infrastructure development priorities revolved around four
key recommendations: to create career paths and core competencies, establish a national
program for service and loan repayment, foster network development and provide technical
assistance to improve the use of information technology. In addition, CSAT placed great
15

emphasis on addictions education and accreditation priorities offering six recommendations
which included: training on addiction in educational curricula, using national core
competencies, developing national accreditation standards, encouraging licensing boards to
include 10 percent addiction content in exams, and supporting academic programs in minority
serving institutions including Historically Black Colleges and Universities. SAMHSA and the
Annapolis Coalition further emphasized the importance of building the capacity of
communities to more effectively identify substance use disorders treatment needs and
understand substance use disorders.

16

Substance use disorders indicators cut across multiple data sets and
public records, including arrest records, domestic violence, child
abuse, hospitalizations, and household surveys, yet most
professionals in the health field are insufficiently trained to recognize or assess key substance
use disorders indicators. This lack of understanding of both the disease of addiction and
treatment options leaves the substance use disorders treatment workforce in a very isolated
position in the community, which could be one further reason for the high rates of turnover and
difficulties in recruitment of qualified, direct service providers. The suggested strategy for
dealing with this is for the substance use disorders workforce to network and build
partnerships with other systems and professions, though there is limited information as to how
this could be achieved.
Leadership and management practices can reduce turnover
The Strengthening Professional Identity report (2006) focused on two key recommendations
related to leadership and management priorities: to develop, deliver and sustain training for
supervisors and to develop, deliver and sustain management development initiatives.
According to the CSAT scan (Kaplan, 2003), management practices that can reduce turnover
include: improved, ongoing clinical supervision, greater job autonomy, better communication
between management and staff, improved recognition and reward systems for performance,
paperwork assistance and improved training programs. This stress on clinical supervision is
supported by Culbreth (1999), who found that counselors want to be supervised by a clinical
supervisor who is certified as an alcohol and drug counselor, has at least a master’s degree or
has a national counselor certification, and considers him/herself a substance use disorders
counselor. Counselors preferred proactive supervision that included goal ‐setting and specific
interventions.
The initial CSAT scan offered a number of recommendations based on the findings of the scan,
including the following: (1) develop career paths for all staff levels to encourage personnel to
see substance use disorders counseling as a profession, (2) develop executive management
curricula to train the next generation of supervisors, managers, and leaders (3) focus on clinical
supervisors, using curricula that include clinical as well as management/supervision training,
(4) conduct a study on staff turnoverʹs costs to agencies and the substance use disorders
treatment system (5) establish an accreditation process for substance use disorders training and
academic programs (6) establish standards for in ‐service training and (7) develop standard
guidelines for internships.

17

The current substance use disorders workforce showed some
consensus around the top four things that an agency could do to
promote retention: more frequent salary increases, more individual
recognition and appreciation, reduction of or assistance with the amount of paperwork, and
more and improved ongoing training (RMC 2003a). Other studies pointed to enhancing career
growth opportunities, providing better benefits, automatic COLA increases, and tiered
compensation levels and bonuses for staff when they become credentialed (RMC 2003b;
OASAS, 2002). The current substance use disorders workforce further indicated the most
frequently cited sources of satisfaction, which included: having a role as a change agent, client
commitment to treatment, one‐on‐one interactions with clients and agency coworkers, and
personal growth opportunities (RMC 2003a, RMC 2003b).
There needs to be a renewed focus on recruitment and retention processes
The Strengthening Professional Identity report (2006) advocated for a multi‐level systematic
approach to recruitment and retention strategies at the federal, state, and local levels.
Retirement, career advancement, administrative burden, low compensation, and job
dissatisfaction contribute to high levels of turnover. There are insufficient substance use
disorders professionals graduating to keep up with annual turnover, especially in rural areas. In
addition, the workforce is not racially and ethically representative of the treatment population.
As salary and benefits for substance use disorders treatment work are lower than mental health
and nursing (U.S. Department of Labor, 2000), salary strategies such as loan forgiveness, tuition
assistance, salary and compensation research, and career advancement options could be
promoted. Strategies specific to recruiting racially and ethnically diverse staff in addition to
strategies that relate to the needs of rural communities are needed to recruit, train, and support
substance use disorders professionals.
The Strengthening Professional Identity report (2006) offered four key recruitment priorities: to
expand recruitment for addictions medicine, improve recruitment in educational institutions
particularly for under‐represented groups, employ marketing strategies to recruit staff, and
reduce the stigma of the field. These priorities were supported by the Annapolis
Coalition/SAMHSA (2007) report, which stipulated the importance of leadership development,
with the understanding that the “graying” of the substance use disorders leadership
emphasizes the need for training stipend and leadership development initiatives that will
support new entry into the field and sustain professional development. Annapolis
Coalition/SAMHSA advocated for an improved training and education process to ensure it is
relevant, effective, and accessible. It is critical to establish a standardized education and training
process that will reflect current best educational practices for preparing and updating addiction
professionals and advocates. These model competency ‐based addiction standards should be
developed with input from clinicians, researchers, educators, and advocates and become the
guide for the development of accreditation standards. In addition, loan ‐forgiveness and
recruitment programs should be targeted to much ‐needed rural and race/ethnicity populations.
All three reports focus on the need to prioritize the identification and dissemination of best
18

practices that address retention within the workforce.

19

Factors impacting retention include salary, tenure, education, and
workload
Knudsen, Johnson & Roman (2003) examined the relationships
between management practices, organizational commitment, and turnover intention among
substance use disorders treatment counselors in privately funded agencies. The survey sampled
1,074 counselors from 345 randomly selected privately funded treatment centers. They found
that older counselors and those with longer tenure had significantly higher commitment than
younger and less tenured staff. Increased education was negatively associated with
commitment, meaning that counselors with greater human capital resources (educated and
certified) reported greater turnover intention. Salary was negatively associated with intention to
quit; that is, higher salary resulted in less intention to quit.
In a number of studies, low salaries have repeatedly been cited as the major cause of staff
turnover and the biggest issue in staff recruitment and retention (RMC 2003a; RMC 2003b;
Gallon et al 2003; Lewin ‐VHI 1994; NAADAC 2003; Knudsen, Johnson & Roman 2003). In focus
groups conducted throughout New York State, salary was identified by the eleven workforce
development focus groups as the single most important issue for staff recruitment and retention
(OASAS, 2002). In addition to salaries, staff reported that documentation and paperwork took
them away from working with clients (McLellan et al 2003; OASAS 2002; RMC 2003a; RMC
2003b). Other barriers cited were long hours and large caseloads (RMC 2003b.)
Early substance use disorders treatment staff show lower levels of job satisfaction
Early career members indicated the greatest dissatisfaction with salary, workload and the
amount of time they have for their clients (NAADAC 2003). Regardless of dissatisfaction with
salary or workload and the finding that only about half of early career members see
opportunities for career advancement in the substance use disorders field, more than 86 percent
overall indicated that it is likely or very likely that they will pursue a long‐term career in the
field. This finding is consistent across all age categories. However, 21 percent of those with less
than two years experience indicated that it was unlikely or very unlikely that they will continue
in this career choice, indicating that there is a need to enhance job satisfaction and retention for very
new addiction counselors (NAADAC 2003).
There is a dearth of research and evaluation data to inform workforce development efforts
Both the SAMHSA/CSAT (CSAT, 2003; Abt Associates, 2006) and the Annapolis
Coalition/SAMHSA (2007) reports denoted the importance of an improved research and
evaluation focus that will enhance the infrastructure for workforce development efforts. These
reports stipulated the lack of reliable data to inform workforce practices. There is no
coordinated national resource center to provide leadership in infrastructure development. The
recommendation is that SAMHSA establish a national Workforce Development Office to
oversee ongoing infrastructure development. A key component of this process would be the
need to upgrade reimbursement rates for addiction treatment and recovery services, which are
currently not based on research‐based provider costs and do not cover the actual costs of these
20

services. This situation results in treatment services being underfunded, staff being poorly
compensated, a lack of career advancement opportunities, and ultimately, barriers to the
ongoing development of a professional workforce that produces improved outcomes for
clients.

21

Both the Annapolis Coalition/SAMHSA (2007) and The
Strengthening Professional Identity report (2006) reports critiqued
the lack of data to inform workforce practices and initiatives and
concluded it is imperative to build a strong workforce research and evaluation base, especially
in relation to the effectiveness of practices that enable recruitment, retention, education, and
training of qualified professionals. This research agenda should recognize that co ‐occurring
mental and substance use disorders are common and place emphasis on the adoption of
empirically tested cost ‐effective practices. The Strengthening Professional Identity report (2006)
recommended three general areas of study: to examine relationships among education, training
and treatment outcomes; investigate clinician and patient/client characteristics related to
outcomes; and assess clinician characteristics that enhance therapeutic alliance. The Annapolis
Coalition/SAMHSA report (2007) identified some key research questions that could be included
as research priorities:
a. What is the importance of supervisory observation, feedback, and coaching to the successful
adoption of empirically supported treatment interventions?
b. What is the relationship between level and type of service, provider education and training
and behavioral health treatment outcomes?
c. How do clinician and patient cultural and demographic characteristics affect treatment
outcomes?
d. What clinician characteristics enhance the therapeutic alliance and lead to improved
outcomes?
e. What is the impact of reimbursement rates, salary levels, and working conditions on
treatment providers and how do those conditions affect client care?

Limitations of current data available: Further questions
What are the best practices related to workforce development and how can these be implemented
effectively?
One key gap in our understanding of preparation, recruitment, retention, and maintenance of
the workforce relates to the limited knowledge around identifying and disseminating best
practices. While much of the literature makes recommendations and offers strategies to improve
preparation, recruitment, retention, and maintenance, more information is needed
ȱ

22

related to evidence‐based initiatives that have positively impacted
workforce development. A number of researchers have started to
identify some key strategies related to workforce retention including the importance of
professional development, direct supervision, performance recognition, in ‐service training, and
organizational development (Gallon et al., 2003; Knudsen et al., 2003; Knudsen et al., 2006;
Knudsen et al., 2008), yet little is known about the practical implementation of these strategies
and what is most impactful. Consequently, there is no list of “best practices” related to
preparation, recruitment, retention, and maintenance of the workforce. Strategies and
methodologies referenced include those relevant to professional development, infrastructure
development, leadership and management practices, recruitment and retention processes, and
an improved research and evaluation focus, yet there is limited consensus surrounding how
these are being or could be implemented. It should be noted that ongoing work from The
Annapolis Coalition may be moving some of this work forward.
What are states currently doing to prepare, recruit, retain, and maintain the workforce?
While there are sporadic references to ongoing workforce development efforts across the U.S., it
is unclear whether states are following a clear workforce development plan based on previous
research or how their approach is being informed. As this will have a significant impact on
substance use disorder treatment organizations, it would be useful to have a clear roadmap of
what approaches states are taking in regards to workforce development issues. This would
further be informed by understanding the relationship between state reimbursement rates and
workforce development issues.

Recommendations
Include questions related to ongoing professional development efforts
Professional development questions should include questions relative to managers and
supervisors expectations for staff education and training, concerns over recruitment and
retention, salary and benefits, job security, and opportunities for advancement. Financial
support for professional development should be identified.
Include questions related to ongoing leadership and management efforts
To understand how organizations are implementing leadership and management practices to
improve workforce development, questions in the survey should include approaches toward
clinical supervision, job autonomy, training, standards, communication channels between
management and staff, performance and reward systems, and paperwork. Specific questions
should also be included related to approaches to retention of entry ‐level or early career
professionals.
Use the SAMHSA/CSAT recommendations to create survey items

23

To address the preparation, recruitment, retention, and
maintenance of the workforce, we believe it is essential to follow
the mandates of the CSAT Strengthening Professional Identity and the SAMHSA/Annapolis
Coalition recommendations. In general, both appear to have major consistencies. The
recommendations suggest specific topics that might be addressed in the survey. The remaining
task for the survey development is the creation of useful items that provide information on
these important areas. Through the discussions with experts and stakeholders a major effort
will be given to developing, prioritizing and refining questions that could be included in the
survey.
Assess the state responses to substance use disorder treatment workforce development
Targeted stakeholder discussions should include questions related to how states are
approaching substance use disorder treatment workforce development to assess which states
are following a comprehensive action plan and how effective their methods have been to date.
This could include questions related to ongoing data collection and understanding of current
workforce needs in relation to substance use disorder treatment staff. The assumption is that
there may be fragmented, uncoordinated efforts to improve workforce development both
within and across states. While states and organizations need to follow workforce development
plans that meet their needs, it is incumbent on the field to catalog these efforts and ensure
effective approaches can be replicated.

24

Summary
The objectives of the national substance use disorders treatment workforce survey are to
understand the demographics of the current workforce and how this differs across regions, in
addition to exploring issues related to workforce development: 1. Staff training, recruitment and
retention; 2. Professional development; and 3. Support for strategies and methodologies to
prepare, recruit, retain, and sustain the workforce. This proposed survey will be used to address
some of the limitations highlighted and to gather data to guide the formation of effective
policies and strategies aimed at successfully recruiting and retaining a sufficient number of
adequately prepared providers who are able to respond to the growing needs of those affected
by substance use problems and disorders.

Summary of the basic demographics of the workforce
What is known?
•
The substance use disorders workforce is diverse in discipline and setting
•
The workforce is older, white, and predominantly female
•
The workforce demographics do not reflect the treatment population
•
The workforce is well ‐educated, though exact data is unclear
•
Turnover rates are high, but professionals seem to stay in the substance use disorders
field
•
Salaries for substance use disorders professionals are low and impact retention rates
Further questions?
•
How accurately do the findings reflect the state of the field?
•
How does turnover in an agency correlate with turnover in the field?
•
How do turnover rates differ by age and what are the implications of this?
Recommendations
•
Standardize organizational definitions and improve response rates
•
Include standardized individual and organizational demographics in addition to
retention indicators

Summary of the anticipated workforce development needs for 2010 ‐2015
What is known?
•
There is insufficient treatment capacity to workforce to meet current and future
demands
•
Myriad trends will impact future recruitment and retention of the workforce
Further questions?
•
What are annual staff turnover rates and staffing needs?
•
How are client demographics changing?
•
What is the relationship between education, training, and treatment outcomes?
25

Recommendations

26

•
•
•

Include annual turnover rates and current staffing needs
Include questions related to changing client demographics
Assess the possibility of including treatment outcomes

Summary of the common strategies and methodologies to prepare, retain, and maintain the
workforce
What is known?
•
There is a general national consensus around workforce development recommendations
•
Professional development strategies are key to retaining and maintaining a strong
workforce
•
There is a need to develop infrastructure around substance use disorder treatment
•
Leadership and management practices can reduce turnover
•
There needs to be a renewed focus on recruitment and retention processes
•
Factors impacting retention include salary, tenure, education, and workload
•
Early substance use disorders treatment staff show lower levels of job satisfaction
•
There is a dearth of research and evaluation data to inform workforce development
efforts
Further questions?
•
What are the best practices related to workforce development and how can these be
implemented effectively?
•
What are states currently doing to prepare, recruit, retain, and maintain the workforce?
Recommendations
•
Include questions related to ongoing professional development efforts
•
Include questions related to ongoing leadership and management efforts
•
Use the SAMHSA/CSAT recommendations to create survey items
•
Assess the state responses to substance use disorder treatment workforce development

27

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Office of Alcoholism and Substance Abuse Services
(OASAS). (2002). The Addictions Profession: A Workforce in
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30

Appendix
Work force survey methods
In preparation of the review, we examined the workforce surveys that have been completed.
Table 1 shows the year in which the survey was conducted. We also checked the sampling
frame reported in the survey against the National Survey of Substance Abuse Treatment
Services for the same year. We also attempted to determine if the data was based on a random
probability sample (R) or a census of agencies (C). The size of the sample was based on the
reported number of agencies included. The response number was the number of agency
director reports included in the data base. The rate was a simple calculation of the number of
agency directors responding divided by the total number of agencies in the sample. Some
studies also included staff surveys. In the final column we recorded the number of agencies
with either a staff or a director survey. Question marks (???) indicate it was not possible to
discern this information from the survey results published.
Noting that many of these surveys were conducted in order to obtain a general sense of
workforce development needs within a given region so as to inform ATTC program planning,
an examination of each survey is helpful in determining how reliable the data is for use in other
settings and for other purposes. Examining the nature of the sample, the consistency of the
sampling and N‐SSATS frames, and the proportion of agencies reporting suggests the academic
rigor of the survey and the confidence one can have in the results reported. Bias in any of the
indicators suggests the extent to which the results may differ from the actual profile of the
workforce in the state agencies. For example, if a low response rate is reported, a
disproportionate percentage of older Caucasian women may have responded to the survey
leading to the erroneous conclusions that the workforce is predominantly older Caucasian
women.

31

Table 1. Brief Overview of Completed Workforce Survey Studies

WORKFORCE SURVEY
Studies
STATE

Year

N‐SSATS

Agencies

Sam/Cen

Size

Responses

Rate

W/Staff

Alaska
Hawaii
Idaho
Oregon
Wash

2005
2005
2005
2005
2005

65
88
67
221
355

64
31
88
250
503

C
C
C
C
C

63
30
56
148
377

41
21
33
101
263

65%
70%
59%
68%
70%

41
22
34
143
302

Arizona

2002

202

???

C

???

???

???

California

2002

1753

???

R

190

???

19%

New Mexico

2002

114

???

C

???

???

???

???

382

???

???

???

???

???

Arkansas
Missouri
Oklahoma

2004
2004
2004

64
216
156

34
190
125

C
R
R

34
76
75

16
24
34

47%
32%
45%

Louisiana

2004

179

???

???

???

???

???

Texas

2005

498

???

???

75

60

80%

Alabama

2006

126

???

C

???

72

???

Florida

2004

573

400

C

400

67

17%

Delaware

2003

40

44

C

42

17

40%

Kentucky

2002

306

27

C

27

20

74%

Maryland

2005

352

275

R

138

58

42%

Tennessee

2004

182

???

C/R

123

52

42%

New Jersey

2004

327

192

R

66

???

???

Puerto Rico

2002

110

77

C

77

72

94%

Connecticut
Maine
Massachusetts
New Hampshire
Rhode Island
Vermont

2003
2003
2003
2003
2003
2003

244
173
345
83
54
37

???
???
???
???
???
???

R
R
R
R
R
R

11
28
28
24
19
12

???
???
???
???
???
???

???
???
???
???
???
???

Colorado

24
63
49

42

32

10
23
23
21
18
10

33

Attachment 7: Estimated Hourly Wages for Clinical Directors and
Thought Leaders

1

2

Attachment 8: Map of N-SSATS Facilities by ATTC Region

1

2

Attachment 9: Table of Substance Use Disorder Facilities by ATTC
Region

1

REGION
Pacific Southwest

Northwest Frontier

Mountain West

Mid America

Northeast

Prairielands

New England

Central East

STATE
Arizona
New Mexico
California
Alaska
Washington
Oregon
Idaho
Hawaii
Pacific Islands
Nevada
Montana
Wyoming
Utah
Colorado
Missouri
Kansas
Oklahoma
Arkansas
New York
New Jersey
Pennsylvania
Iowa
North Dakota
South Dakota
Minnesota
Nebraska
Connecticut
Rhode Island
Maine
New Hampshire
Vermont
Massachusetts
District of
Columbia
Delaware
Maryland

NO. OF NSSATS
FACILITIES

REGION
REGION
STATE
TOTAL
WEIGHT
WEIGHT
212
2082
0.15
0.10
145
0.07
1725
0.83
71
949
0.07
0.07
436
0.46
236
0.25
77
0.08
123
0.13
6
0.01
77
778
0.06
0.10
63
0.08
56
0.07
146
0.19
436
0.56
257
723
0.05
0.36
221
0.31
186
0.26
59
0.08
964
1846
0.13
0.52
331
0.18
551
0.30
113
641
0.05
0.18
64
0.10
64
0.10
286
0.45
114
0.18
203
855
0.06
0.24
53
0.06
177
0.21
61
0.07
45
0.05
316
0.37
44
39
371

952

0.07

0.05
0.04
0.39
2

Gulf Coast

Great Lakes

Southeast
Southern Coast
Mid Atlantic

Carribean Basin
TOTAL (US)

Kentucky
Tennessee
Texas
Louisiana
Mississipi
Illinois
Ohio
Wisconsin
Indiana
Michigan
Georgia
South Carolina
Alabama
Florida
Virginia
Maryland
North Carolina
West Virginia
Virgin Islands
Puerto Rico

301
197
480
166
102
608
402
279
313
512
265
111
136
644
199
371
410
79
2
151
14056

748

0.05

2114

0.15

376

0.03

780

0.06

1059

0.08

153

0.01

14056

1.00

0.32
0.21
0.64
0.22
0.14
0.29
0.19
0.13
0.15
0.24
0.70
0.30
0.17
0.83
0.19
0.35
0.39
0.07
0.01
0.99
14.00

3

4

Attachment 10: Estimated Costs for National and Regional Sample

1

Attachment 10

Estimated costs for national and regional sample

Costs for national sample

While there may be some variation in costs, the following information was used to derive
approximate labor costs for the national sample: each survey would equate to 1 hour per I-SATS
facility plus 1 hour at ATTC regional center based on a salary of $23.11 per hour for clinical
supervisors (May 2008 Occupational Employment Statistics, Bureau of Labor Statistics); one
month of statistical consultation based on salary of $65 per hour for 160 hours ($10,400). These
data were included with Table 5 data to provide estimated costs for the national sample.

Estimates of Costs Relative to the Sample Size Needed for Nationally Representative Sample

Sample size for the 95% confidence level with maximum variance
(50/50 split)

± 10%

± 5%

± 3%

sampling error

sampling error

sampling error

96

374

989

$14,837

$27,686

$56,112

Population size

14,056
Cost estimate

Costs for regional sample

2

While there may be some variation in costs, the following information was used to derive
approximate labor costs for the national sample: each survey would equate to 1 hour per I-SATS
facility and collating data would result in approximately 10 hours at each ATTC regional center
based on a salary of $23.11 per hour for clinical supervisors (May 2008 Occupational
Employment Statistics, Bureau of Labor Statistics); one month of statistical consultation based
on salary of $65 per hour for 160 hours ($10,400). These data were included with Table 7 data
to provide estimated costs for the regional sample. The lower costs associated with the labor of
the ATTC regions are due to the collating of data needed (after initial data training related to the
national sample is conducted). What these costs do not take into account are the anticipated
overlaps between samples, which will reduce costs significantly.

Estimates of Costs Relative to the Sample Size Needed for Regionally Representative Sample
(regional costs included in overall figure)

Sample size for the 95% confidence level with maximum variance
(50/50 split)
Effect size

0.25
Costs overall
(region)
0.15
Costs overall
(region)

± 10%

± 5%

± 3%

sampling error

sampling error

sampling error

316 (23)

437 (31)

523 (37)

$20,938 ($10,538)

$23,734 ($13,334)

$25,722 ($15,322)

858 (61)

1192 (85)

1430 (102)

$33,464 ($23,064)

$41,183 ($30,783)

$46,683 ($36,283)

Notes of caution

The extra costs for including the phase 2 regional data will be a minimum of $13,635 due to the
fixed costs of 140 hours of ATTC regional work (10 hours per region for collating data), plus the
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statistical consulting needed for analysis. The costs associated with this study cannot simply be
assessed by adding the costs for the national sample with the costs for the regional sample. It is
anticipated that there will be significant overlap between the two samples, but as phase 1 (the
national data) will be random, it is unlikely it will provide the individual regional sample
numbers needed for phase 2 data. Looking at Attachment 9, one example for this is that the
Pacific SouthWest region has approximately 2082 substance use disorder organizations (15% of
the total population) whereas the Southeast has 376 substance use disorder organizations (3% of
the total population). If a random national sample of 989 selects 148 organizations (or 15%)
from the Pacific Southwest region and only 30 (3%) from the Southeast region, the Southeast
region may need to be supplemented in the Phase 2 data collection effort. A fair and
conservative estimate of extra costs associated with a regional data collection effort could then
approximate a range of $13,635 (for fixed costs) to a conservative estimate of $31,777 (based on
the small effect size of 0.15, the 3% margin of error, and the conservative assumption that at
least half of the national sample would fulfill the sampling needs of the regional sample).

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