Predicting and responding to change: Perceived environmental uncertainty among substance use disorder treatment programs

INTRODUCTION

Substance use disorder (SUD) treatment programs offering addiction health services (AHS) must be prepared to adapt to change in their operating environment. These environmental uncertainties may have implications for service delivery, and ultimately patient outcomes. To adapt to a multitude of environmental uncertainties, treatment programs must be prepared to predict and respond to change. Yet, research on treatment programs preparedness for change is sparse. We examined reported difficulties in predicting and responding to changes in the AHS system, and factors associated with these outcomes.

METHODS

Cross-sectional surveys of SUD treatment programs in the United States in 2014 and 2017. We used linear and ordered logistic regression to examine associations between key independent variables (e.g., program, staff, and client characteristics) and four outcomes, (1) reported difficulties in predicting change, (2) predicting effect of change on organization, (3) responding to change, and (4) predicting changes to make to respond to environmental uncertainties. Data were collected through telephone surveys.

RESULTS

The proportion of SUD treatment programs reporting difficulty predicting and responding to changes in the AHS system decreased from 2014 to 2017. However, a considerable proportion still reported difficulty in 2017. We identified that different organizational characteristics are associated with their reported ability to predict or respond to environmental uncertainty. Findings show that predicting change is significantly associated with program characteristics only, while predicting effect of change on organizations is associated with program and staff characteristics. Deciding how to respond to change is associated with program, staff, and client characteristics, while predicting changes to make to respond is associated with staff characteristics only.

CONCLUSIONS

Although treatment programs reported decreased difficulty predicting and responding to changes, our findings identify program characteristics and attributes that could better position programs with the foresight to more effectively predict and respond to uncertainties. Given resource constraints at multiple levels in treatment programs, this knowledge might help identify and optimize aspects of programs to intervene upon to enhance their adaptability to change. These efforts may positively influences processes or care delivery, and ultimately translate into improvements in patient outcomes.

Availability of Medications for the Treatment of Alcohol and Opioid Use Disorder in the USA

Despite high mortality rates due to opioid overdose and excessive alcohol consumption, medications for the treatment of alcohol and opioid use disorder have not been widely used in the USA. This paper provides an overview of the literature on the availability of alcohol and opioid used disorder medications in the specialty substance use disorder treatment system, other treatment settings and systems, and among providers with a federal waiver to prescribe buprenorphine. We also present the most current data on the availability of alcohol and opioid use disorder medications in the USA. These estimates show steady growth in availability of opioid use disorder medications over the past decade and a decline in availability of alcohol use disorder medications. However, overall use of medications in the USA remains low. In 2017, only 16.3% of specialty treatment programs offered any single medication for alcohol use disorder treatment and 35.5% offered any single medication for opioid use disorder treatment. Availability of buprenorphine-waivered providers has increased significantly since 2002. However, geographic disparities in access to buprenorphine remain. Some of the most promising strategies to increase availability of alcohol and opioid use disorder medications include the following: incorporating substance use disorder training in healthcare education programs, educating the substance use disorder workforce about the benefits of medication treatment, reducing stigma surrounding the use of medications, implementing medications in primary care settings, implementing integrated care models, revising regulations on methadone and buprenorphine, improving health insurance coverage of medications, and developing novel medications for the treatment of substance use disorder.

Treatment strategy profiles in substance use disorder treatment programs: A latent class analysis

BACKGROUND

Modern treatment options for substance use disorder are diverse. While studies have analyzed the adoption of individual evidence-based practices in treatment centers, little is known about the specific make-up of treatment strategy profiles in treatment centers throughout the United States. The current study used latent class analysis to profile underlying treatment strategies and to evaluate philosophical and structural supports associated with each profile.

METHODS

Utilizing three aggregated and secondary datasets of nationally representative samples of substance use disorder treatment centers (N=775), we employed latent class analysis to determine treatment strategy profiles. Using multinomial logistic regression, we then examined organizational characteristics associated with each profile.

RESULTS

We found three distinct treatment strategy profiles: centers that primarily relied on motivational interviewing and motivational enhancement therapy, centers that utilized psychosocial and alternative therapies, and centers that employed comprehensive treatments including pharmacotherapy. The multinomial logistic regression revealed that philosophical and structural center characteristics were associated with membership in the comprehensive class. Centers with philosophical orientations conducive to holistic care and pharmacotherapy-acceptance, resource-rich infrastructures, and an entrepreneurial reliance on insured clients were more likely to offer diverse interventions. All associations were significant at the .05 level.

PRINCIPLE CONCLUSION

The findings from this study help us understand the general strategies of treatment centers. From a practical perspective, practitioners and clients should be aware of the variation in treatment center practices where they may offer or receive treatment.

Adoption and diffusion of evidence-based addiction medications in substance abuse treatment

OBJECTIVE

To examine the roles of facility- and state-level factors in treatment facilities' adoption and diffusion of pharmaceutical agents used in addiction treatment.

DATA SOURCES

Secondary data from the National Survey of Substance Abuse Treatment Services (N-SSATS), Substance Abuse and Mental Health Services Administration (SAMHSA), Centers for Medicare and Medicaid Services, Alcohol Policy Information System, and Kaiser Family Foundation.

STUDY DESIGN

We estimate ordered logit and multinomial logit models to examine the relationship of state and treatment facility characteristics to the adoption and diffusion of three pharmaceutical agents over 4 years when each was at a different stage of adoption or diffusion.

DATA COLLECTION

N-SSATS data with facility codes, obtained directly from SAMHSA, were linked by state identifiers to the other publicly available, secondary data.

PRINCIPAL FINDINGS

The analysis confirms the importance of awareness and exposure to the adoption behavior of others, dissemination of information about the feasibility and effectiveness of innovations, geographical clustering, and licensing and accreditation in legitimizing facilities' adoption and continued use of pharmacotherapies in addiction treatment.

CONCLUSIONS

Policy and administrative levers exist to increase the availability of pharmaceutical technologies and their continued use by substance abuse treatment facilities.

A qualitative study of the adoption of buprenorphine for opioid addiction treatment

Qualified physicians may prescribe buprenorphine to treat opioid dependence, but medication use remains controversial. We examined adoption of buprenorphine in two not-for-profit integrated health plans, over time, completing 101 semi-structured interviews with clinicians and clinician-administrators from primary and specialty care. Transcripts were reviewed, coded, and analyzed. A strong leader championing the new treatment was critical for adoption in both health plans. Once clinicians began using buprenorphine, patients' and other clinicians' experiences affected decisions more than did the champion. With experience, protocols developed to manage unsuccessful patients and changed to support maintenance rather than detoxification. Diffusion outside addiction and mental health settings was nonexistent; primary care clinicians cited scope-of-practice issues and referred patients to specialty care. With greater diffusion came questions about long-term use and safety. Recognizing how implementation processes develop may suggest where, when, and how to best expend resources to increase adoption of such treatments.

Timing of buprenorphine adoption by privately funded substance abuse treatment programs: the role of institutional and resource-based interorganizational linkages

Identifying facilitators of more rapid buprenorphine adoption may increase access to this effective treatment for opioid dependence. Using a diffusion of innovations theoretical framework, we examine the extent to which programs' interorganizational institutional and resource-based linkages predict the likelihood of being an earlier adopter, later adopter, or nonadopter of buprenorphine. Data were derived from face-to-face interviews with administrators of 345 privately funded substance abuse treatment programs in 2007-2008. Results of multinomial logistic regression models show that interorganizational and resource linkages were associated with timing of adoption. Programs reporting membership in provider associations were more likely to be earlier adopters of buprenorphine. Programs that relied more on resource linkages, such as detailing activities by pharmaceutical companies and the National Institute on Drug Abuse website, were more likely to be earlier adopters of buprenorphine. These findings suggest that institutional and resource-based interorganizational linkages may expose programs to effective treatments, thereby facilitating more rapid and sustained adoption of innovative treatment techniques.

Facilitating factors and barriers to the use of medications in publicly funded addiction treatment organizations

OBJECTIVES

Publicly funded addiction treatment organizations have been slow to adopt pharmacotherapies. Few studies have examined the organizational factors associated with adoption of different types of medication in this treatment sector. This study identifies organization-level facilitators and barriers to the use of medications in publicly funded addiction treatment organizations.

METHODS

Face-to-face interviews with a sample of 318 administrators of a representative sample of publicly funded addiction treatment centers in the US.

RESULTS

Only 23.4% of programs reported using any of the five FDA-approved pharmacotherapies for treating addiction. An additional 14.3% of programs only used medications approved for the treatment of psychiatric disorders. Multivariate multinomial logistic regression results revealed that the odds of adoption of addiction pharmacotherapies were significantly greater in government-owned programs and in programs with more medical personnel. Programs that relied more heavily on non-Medicaid public funding tended to be less likely to adopt addiction treatment medications. Greater contact with pharmaceutical representatives was positively associated with medication adoption.

CONCLUSIONS

Current public funding policies and lack of access to medical personnel are barriers to the adoption of medications by publicly funded addiction treatment organizations. Efforts to promote adoption may also benefit from greater detailing activities by pharmaceutical representatives. These findings suggest that the large research investment devoted to developing addiction treatment medications may have limited public health impact due to the characteristics of publicly funded service delivery system as well as the limited attention given to this system by commercial purveyors of medications.

Adoption and implementation of medications in addiction treatment programs

OBJECTIVES

Little is known about the extent to which medications are being implemented as routine care in addiction treatment programs. This research describes medication adoption and implementation within the privately funded treatment sector.

METHODS

Face-to-face interviews were conducted with 345 administrators of a nationally representative sample of privately funded substance treatment organizations in the United States.

RESULTS

Rates of adoption of addiction treatment medications in private sector programs were lower than the adoption of psychiatric medications. Even when analyses were restricted to programs with access to physicians, adoption of each addiction treatment medication had occurred in less than 50% of programs. Within adopting programs, implementation was highly variable. While about 70% of patients with co-occurring psychiatric diagnoses received psychiatric medications, rates of implementation of medication-assisted treatment for opioid dependence and alcohol use disorders were just 34.4% and 24.0%, respectively.

CONCLUSIONS

Although previous research has documented higher rates of medication adoption in privately funded treatment programs, this study revealed that both adoption and implementation of pharmacotherapies to treat addiction remains modest. Future research should examine the different types of barriers to implementation, such as physician decision-making, patient preferences, and system-level barriers stemming from financing and public policy.

Using medication-assisted treatment for substance use disorders: evidence of barriers and facilitators of implementation

The use of medications to treat substance use disorders (SUDs) has emerged as a potentially central part of the treatment armamentarium. In this paper we present data from several recent US national surveys showing that despite the clinical promise of these medications, there has been limited adoption of pharmacotherapies in the treatment of SUDs. The data reveal variable patterns of use of disulfiram, buprenorphine, tablet naltrexone, acamprosate and injectable naltrexone. After examining the environmental and institutional context for the adoption of pharmacotherapies, the specific organizational facilitators and barriers of medication adoption are considered. The paper concludes with a discussion of the minimal clinical and administrative guidance available to enhance adoption, the lack of client and consumer knowledge of medications that puts a brake on their adoption and availability, and the difficulties that must be surmounted in bringing new medications to market.

Counselor attitudes toward the use of naltrexone in substance abuse treatment: a multi-level modeling approach

Alcohol use disorders (AUDs) continue to be one of the most pervasive and costly of the substance use disorders (SUDs). Despite evidence of clinical effectiveness, adoption of medications for the treatment of AUDs is suboptimal. Low rates of AUD medication adoption have been explained by characteristics of both treatment organizations and individual counselor's attitudes and behaviors. However, few studies have simultaneously examined the impact of organizational-level and counselor-level characteristics on counselor perceptions of EBPs. To address this gap in the literature, we use data from a national sample of 1178 counselors employed in 209 privately funded treatment organizations to examine the effects of organizational and individual counselor characteristics on counselor attitudes toward tablet and injectable naltrexone. Results of hierarchical linear modeling (HLM) show that organizational characteristics (use of tablet/injectable naltrexone in the program, 12-step orientation) were associated with counselor perceptions of naltrexone. Net of organizational characteristics, several counselor level characteristics were associated with attitudes toward tablet and injectable naltrexone including gender, tenure in the field, recovery status, percentage of AUD patients, and receipt of medication-specific training. These findings reveal that counselor receptiveness toward naltrexone is shaped in part by the organizational context in which counselors are embedded.

Organizational-level correlates of the provision of detoxification services and medication-based treatments for substance abuse in correctional institutions

In recent years, there has been an increased examination of organizational-level innovation adoption in substance abuse treatment organizations. However, the majority of these studies have focused on community-based treatment centers. One understudied area of the substance abuse treatment system is correctional institutions. This study uses the Criminal Justice Drug Abuse Treatment Studies (CJ-DATS) cooperative's National Criminal Justice Treatment Practices (NCJTP) survey to examine the adoption of detoxification services and pharmacotherapies for the treatment of substance abuse across a nationally representative sample of correctional institutions (n=198). There were significant differences between jails and prisons in the percentage of organizations offering detoxification services and medications. Specifically, detoxification services were offered by 5% of prisons and 34% of jails; and, medications were offered by 6% of prisons and 32% of jails. Binary logistic regression models were used to examine the associations between these services and organizational characteristics, including context, resources, previously introduced practices, culture, and systems integration. Variables measuring organizational context and previously introduced practices were significant correlates of the provision of both detoxification services and medications. Multivariate results indicated that the differences between jails and prisons remained significant after controlling for other organizational factors. Although the adoption of detoxification services and pharmacotherapies may be a controversial topic for correctional institutions, these services have the potential to improve offender well-being and reduce public health risks associated with substance abuse.

Racial and Ethnic Composition as a Correlate of Medication Availability within Addiction Treatment Organizations

Most analyses of racial and ethnic disparities in healthcare focus on individuals rather than organizations. Healthcare organizations may be one mechanism that produces disparities if the representation of minorities within organizations' patient populations is associated with differential patterns of service delivery. This research considers whether the racial and ethnic composition of addiction treatment centers' caseloads is associated with the likelihood that organizations offer any prescription medications to treat addiction, psychiatric conditions, or pain. Data were collected from 288 publicly-funded substance abuse treatment centers in the US. Logistic regression was used to estimate models of medication availability. The percentage of racial and ethnic minority patients was negatively associated with the odds of medication availability, even after controlling for organizational characteristics and patients' diagnostic characteristics. Future research should continue to investigate how healthcare organizations may produce inequalities in access to high-quality care.

Research on the diffusion of evidence-based treatments within substance abuse treatment: a systematic review

This article provides a comprehensive review of research studies that have examined the diffusion of evidence-based treatments (EBTs) within the field of substance abuse treatment. Sixty-five research studies were identified and were grouped into one of three major classifications: attitudes toward EBTs, adoption of EBTs, and implementation of EBTs. This review suggests significant progress has been made with regard to the advancement of the fields' knowledge about attitudes toward and the extent to which specific EBTs have been adopted in practice, as well as with regard to the identification of organizational factors related to EBT adoption. In an effort to advance the substance abuse treatment field toward evidence-based diffusion practices, recommendations are made for greater use of methodologically rigorous experimental or quasi-experimental designs, psychometrically sound instruments, and integration of quantitative and qualitative data collection.

State policy influence on the early diffusion of buprenorphine in community treatment programs

BACKGROUND

Buprenorphine was approved for use in the treatment of opioid dependence in 2002, but its diffusion into everyday clinical practice in community-based treatment programs has been slow. This study examines the net impact of efforts by state agencies, including provision of Medicaid coverage, on program-level adoption of buprenorphine as of 2006.

METHODS

Interviews were conducted with key informants in 49 of the 50 state agencies with oversight responsibility for addiction treatment services. Information from these interviews was integrated with organizational data from the 2006 National Survey of Substance Abuse Treatment Services. A multivariate logistic regression model was estimated to identify the effects of state efforts to promote the use of this medication, net of a host of organizational characteristics.

RESULTS

The availability of Medicaid coverage for buprenorphine was a significant predictor of its adoption by treatment organizations.

CONCLUSION

Inclusion of buprenorphine on state Medicaid formularies appears to be a key element in ensuring that patients have access to this state-of-the-art treatment option. Other potential barriers to the diffusion of buprenorphine require identification, and the value of additional state-level policies to promote its use should be evaluated.

A categorical typology of naltrexone-adopting private substance abuse treatment centers

This study used a diffusion of innovations theoretical framework [Rogers, E. M. 2003. Diffusion of innovations. 5th edition. New York: The Free Press] to identify organizational-level predictors of a categorical typology of substance abuse treatment centers based on naltrexone adoption. Data from the National Treatment Center Study (N = 158) were used to examine the impact of socioeconomic status, organizational personality, and communication behavior on adopter categorization (i.e., innovators, early adopters, early majority, late majority, or laggards). Results from the ordered logistic regression model indicate that organizations that did not have onsite 12-step meetings and were familiar with treatment innovations were more likely to be in a more innovative category. Organizations that learned about innovations from professional development seminars and informal conversations with external treatment providers were more likely to be in a less innovative category. Identifying and targeting the early and late majority categories of adopting organizations for better training and community linkages could help reduce the research-to-practice gap.

Empirically supported substance abuse treatment approaches: a survey of treatment providers' perspectives and practices

To better understand the extent that empirically supported and promising substance abuse treatment approaches are implemented in community settings, treatment providers were surveyed regarding their perceptions and use of several psychosocial and pharmacological treatment interventions. Program directors (n=30) and staff members (n=331) from diverse community settings rated the effectiveness and extent of use of various treatment interventions, and provided information on program and workforce characteristics via self-administered questionnaires. On average, program directors and staff rated the psychosocial treatment interventions as effective, with the exception of vouchers/motivational incentives. About half of the treatment providers did not know the effectiveness of certain pharmacological treatments, including buprenorphine and naltrexone. Respondents from the majority of programs (55%-80%) reported using Motivational Enhancement Therapy, Community Reinforcement Approach, and Supportive Expressive Psychotherapy. The extent that programs used several of the treatment interventions was related to organizational training and information resources. The study findings provide important information regarding training and research dissemination efforts.

Level of analysis issues in assessing treatment beliefs in substance abuse clinics

The current study applies the growing literature in the organizational sciences regarding levels of analysis issues to the analysis of substance abuse treatment beliefs. Research on clinicians' beliefs in substance abuse treatment is often based on the assumption that the beliefs are sufficiently shared by clinicians within a clinic and sufficiently vary across clinics that they can be treated as a group-level phenomenon. Further, efforts to introduce new innovations are often focused at the group or clinic level without testing this assumption, which can lead to failure to adopt or to successfully implement the innovation. We tested the assumption of sharedness by examining if there was sufficient agreement about treatment beliefs within clinics, within groups of clinics or within groups of clinicians to justify treating these aggregations as meaningful groups. Using three statistical approaches to examining level of analysis (Within and Between Analysis (WABA I), Intraclass Correlation Coefficients (ICC(1)), and r(wg)), we found that variability in treatment beliefs largely occurred at the individual rather than at the tested aggregate levels of analysis. These findings serve as an example of the importance of testing the assumption of shared perceptions in future research.

Use of surveillance data in developing geographic dissemination strategies: a study of the diffusion of olanzapine to Michigan children insured by medicaid

OBJECTIVE

The purpose of this study was to examine the diffusion of olanzapine to urban and rural children insured by Medicaid in Michigan by identifying prescribing clusters through surveillance of claims records.

METHODS

Prescription claims records for all antipsychotic medications for 3,567 children insured by Medicaid in Michigan from 1996 through 1998 were examined through the state Medicaid database. There were 29,069 pediatric prescriptions for antipsychotic medications; 2949 were for olanzapine (576 children, 510 providers). These data were linked to the Area Resource File, Provider Enrollment File, and Rural-Urban Commuting Area codes. Patient and provider locations were geocoded by ZIP code. Mixed logistic regression analysis was performed to determine the probability of a child's being prescribed olanzapine given certain community, patient, and provider characteristics. Spatial clusters were identified through the local Moron's L statistic and empirical Bayes standardized incidence rates.

RESULTS

Rural children were more likely than urban children to be prescribed olanzapine (odds ratio [OR], 1.29; P < 0.001). There were significant differences by age and sex, with older children and girls more likely than younger children and boys to be prescribed olanzapine (OR, 1.30 and 1.37, respectively; both, P < 0.001). At the county level, the number of pediatricians per primary care physician reduced the likelihood of a child's being prescribed olanzapine (OR, 0.88; P = 0.039). The effect of the number of available mental health professionals was not significant. The global Moran's L statistic was U indicating moderate clustering of the use of olanzapine.

CONCLUSION

Graphic surveillance data may be useful for studying the delivery and use of health cue services. Further research is needed to determine how this method can be used strategically to facilitate or impede the diffusion of new medications.

The use of antidepressant medications in substance abuse treatment: the public-private distinction, organizational compatibility, and the environment

Many studies of innovation adoption in health care organizations focus either on organizational characteristics or the institutional environment, but not both. Furthermore, these perspectives are rarely employed simultaneously in both public and private health care organizations. This research considers the public-private distinction, organizational compatibility, and interorganizational referral relationships in the use of selective serotonin reuptake inhibitors (SSRIs) by substance abuse treatment organizations. Using data from nationally representative samples of 363 publicly funded and 403 privately funded substance abuse treatment centers, a four-category typology of public and private organizations initially predicted variation in SSRI use. However some differences were no longer significant once organizational and environmental characteristics were added to the statistical model. These data support hypotheses about the associations between organizational characteristics and SSRI use as well as hypotheses regarding the external environment. Future research should continue to integrate both internal and external factors in theoretical explanations of innovation adoption.

The adoption of medications in substance abuse treatment: associations with organizational characteristics and technology clusters

Despite growing interest in closing the "research to practice gap", there are few data on the availability of medications in American substance abuse treatment settings. Recent research suggests that organizational characteristics may be associated with medication availability. It is unclear if the availability of medications can be conceptualized in terms of "technology clusters", where the availability of a medication is positively associated with the likelihood that other medications are also offered. Using data from 403 privately funded and 363 publicly funded specialty substance abuse treatment centers in the US, this research models the availability of agonist medications, naltrexone, disulfiram, and SSRIs. Bivariate logistic regression models indicated considerable variation in adoption across publicly funded non-profit, government-owned, privately funded non-profit, and for-profit treatment centers. Some of these differences were attenuated by organizational characteristics, such as accreditation, the presence of staff physicians, and the availability of detoxification services. There was some evidence that naltrexone, disulfiram, and SSRIs represent a group of less intensely regulated medications that is distinct from more intensely regulated medications. These types of medications were associated with somewhat different correlates. Future research should continue to investigate the similarities and differences in the predictors of medication availability across national contexts.

Trends in the adoption of medications for alcohol dependence

Increasing attention is being paid to the development and dissemination of effective pharmacotherapies for the treatment of alcohol and other drug dependence. However, numerous structural and philosophical barriers impede the widespread adoption of these treatment approaches in everyday clinical practice. Research is needed to understand and overcome this gap. Drawing upon data collected from 2 large samples of substance abuse treatment providers at multiple time points, this article examines the prevalence and correlates of the adoption of the currently available pharmacotherapies for alcohol dependence: disulfiram, oral naltrexone, and acamprosate. These data suggest that the proportion of treatment programs using pharmacotherapies for alcohol dependence has been declining over time. In addition, the proportion of patients to whom these medications are prescribed is notably low. The adoption of disulfiram and naltrexone is significantly more likely in programs that are accredited, employ at least 1 physician, offer integrated care for patients with co-occurring psychiatric conditions, derive proportionately more revenue from commercial insurance payers, and have fewer linkages with the criminal justice system. Preliminary data suggest that the early adoption of acamprosate is following a similar pattern. Recommendations for addressing challenges to the diffusion of pharmacotherapies for alcohol dependence are presented.

Early adoption of buprenorphine in substance abuse treatment centers: data from the private and public sectors

The recent approval of buprenorphine for the treatment of opiate dependence offers an opportunity to analyze innovation adoption in community-based treatment. Using data collected from national samples of 299 privately funded and 277 publicly funded treatment centers, this research examines buprenorphine adoption using baseline data collected between 2002 and 2004 as well as follow-up data collected 12 months later. Private centers were significantly more likely than public centers to report current use of buprenorphine. The baseline data indicated that early adoption was positively associated with center accreditation, physician services, availability of detoxification services, current use of naltrexone, and the percentage of opiate-dependent clients. Multivariate analyses of follow-up data suggest that adoption was greater in accredited centers, for-profit facilities, organizations offering detoxification services, and naltrexone-using centers. Future research should continue to monitor the extent to which buprenorphine is adopted in these settings.

Patterns of organization and management in private and public substance abuse treatment programs

As an organizational field, substance abuse treatment clearly includes a remarkable range of organizations. Yet only in the past two decades has there been research interest in the organizational context in which treatment is delivered. The goal of this article is to promote the concept of organizational field by summarizing findings from an ongoing research program and by examining the organizational structure, service delivery, and patterns of innovation adoption in two large samples of substance abuse treatment programs in the United States. Among highlighted findings, there are notable differences between the public and private sectors in structural and staffing characteristics, as well as in the characteristics of clients receiving substance abuse treatment. With regard to the use of evidence-based practices, our findings suggest that pharmacotherapies are more likely to be adopted in private centers, whereas notably effective voucher approaches are more common in public centers. Future research directions are discussed.