North Dakota Integration Study

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.

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.

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:

a. 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.

b. Where should services be located? The goal was to locate where services are needed most.

c. 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 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.

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.

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.

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.

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.

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.

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.

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 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).

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.

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.

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:

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

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

● 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.

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.

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.

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.

Table 2.1 Needs Assessment and Planning Process
Study Objectives	Study	Statewide Need	Substate Area Needs	Modality/Service Mix
Background Studies	Interviews with State officials.	Is overall level of services perceived to be adequate? Are there new policy initiatives? What are budget constraints?	Are there specific areas that are thought to be underserved? Are all groups adequately served?	Is the mix of modalities adequate to meet client needs? Is the mix cost-efficient?
	Prior Studies Review including earlier planning studies; time-series indicator and census data	Has problem been increasing? Have services kept pace?	Have there been major demographic changes in North Dakota’s high-risk populations due to migration or birth rate?	Has nature of State’s alcoholism and addiction problem changed significantly (e.g., alcoholics taken up marijuana)? Have treatment services kept up with the changes?
	Literature Review including relevant local and national studies of trends that affect treatment services	Is there a national substance abuse trend that is likely to affect State service system (e.g., AIDS or crack epidemics)?	Is there a mis-allocation of services (e.g., services tend to be in urban areas)?	Are there new modalities such as intensive outpatient detox services that could be more cost-effective than current residential modalities?
Preliminary Analysis	Interstate Comparisons of need indicators and treatment service statistics	Compare North Dakota with other states regarding need indicators, service statistics, and services per unit of need.	Are services in North Dakota more concentrated than they are in other rural states?	Comparison of treatment modality mix for opiate addicts in State with mix in other States: % in each modality
	Social Indicator Study of substance-abuse related variables	Develop validated estimates of need for alcohol- and drug-related treatment	Which substate areas have higher alcohol-related problems? Which have higher drug-related problems?	Placement of alcohol-related services (e.g., detox) vs. placement of drug-related services (e.g., methadone maintenance)
Preparatory Studies	Uncovered Population Estimates using census data and prevalence rates in literature to estimate the substance abuser population not covered by the household telephone survey and the supplementary studies.	Determine statewide population size and number of substance abusers living in households without phones, who are homeless, or who were institutionalized in last year in prison facilities. Find out how many were in long-term residential drug treatment.	Identify where these uncovered populations lived based on analyses of census data, arrest, and prison statistics.	Review literature on program/service needs of special population groups, such as criminal justice populations, homeless, and people in households without telephones.
Gap Analysis	Analysis of Survey and Social Indicators of Need	Estimate the overall services needs. Validate accuracy of combined estimates of the telephone and supplementary surveys.	Create index of survey data and social indicators to estimate needs in substate areas.	Analyze treatment mix data to determine optimal treatment mix.
	Analysis of Service Gaps	Compare total estimates of need and demand from surveys with services to determine how many need and want service but are not obtaining treatment. Recommend increases to fill gaps.	Compare proportion of need in each area compared to the proportion of services. Recommend service allocation changes if needed.	Examine need and demand for individual service mix statewide and compare with services provided or available. Make recommendations to establish program types to fill gaps and improve service mix.
Report Creation	Specific Recommend-ations	Steps to achieve goals and structure	Substate profiles and plans, reallocation plans	Facilities to be added, personnel training, credentials, etc.

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).

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.

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.

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.

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.