California Substance Use Disorder Treatment Facility Characteristics Associated with Offering Medications for Opioid Use Disorder

California Substance Use Disorder Treatment Facility Characteristics Associated with Offering Medications for Opioid Use Disorder | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article California Substance Use Disorder Treatment Facility Characteristics Associated with Offering Medications for Opioid Use Disorder Melanie J Nicholls, Ashley Weitensteiner, Laramie R Smith, Lianne A Urada This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-6307033/v1 This work is licensed under a CC BY 4.0 License Status: Under Revision Version 1 posted 9 You are reading this latest preprint version Abstract Background The use of medication for opioid use disorders (MOUD) are not keeping up with the rise of the opioid epidemic. There is mixed research on how MOUD is utilized in different treatment settings for substance use disorders. This study explored factors influencing the implementation of medication for opioid use disorders (MOUD) in substance use disorder treatment (SUDT) facilities in California. Methods Secondary analyses of the 2019 National Survey of Substance Abuse Treatment Services (N-SSATS) data were conducted, focusing on facility type, funding, and accreditation. Chi-square analyses and multiple logistic regressions were used to examine associations with offering MOUD. Results A total of 1,778 California facilities were surveyed, with 47.7% offering MOUD. Significant differences in facility type and funding sources were observed. Private for-profit facilities were more likely to accept cash/self-payment, federal military insurance, and IHS/tribal/urban funds (all p < .001), while government-owned facilities were more likely to accept government funding, Medicaid, Medicare, and state-financed insurance (all p < .001). Accreditation was associated with accepting cash/self-payment, federal military insurance, and IHS/tribal/urban funds (all p < .001) and was more common in private for-profit facilities (X 2 (2, 1776) = 427.02, p < .001). Logistic regression revealed that government-owned facilities had lower odds of offering MOUD (AOR: 0.33; 95% CI: 0.23, 0.47), while accredited facilities (AOR: 5.23; 95% CI: 3.97, 6.90), those accepting private insurance (AOR: 2.96; 95% CI: 2.10, 4.16), and IHS/Tribal/Urban funds (AOR: 1.49; 95% CI: 1.05, 2.12) had higher odds. Government funding was associated with lower odds (AOR: 0.69; 95% CI: 0.48, 0.98). Conclusions MOUD are underutilized in Californian substance use facilities. Accreditation, funding, and facility type significantly affect MOUD availability. Future policies should focus on increasing accreditation and aligning government funding and insurance with MOUD delivery. Medication for Opioid Use Disorders Implementation Buprenorphine Methadone Treatment INTRODUCTION The opioid epidemic in the United States has worsened with the ever-increasing accessibility of fentanyl, with overdose deaths involving opioids rising from 49,860 in 2019 to 81,806 in 2022. 1 , 2 Medication for opioid use disorder (MOUD) is considered the gold standard by leading organizations such as the Food and Drug Administration (FDA), American Society of Addiction Medicine (ASAM) and the World Health Organization (WHO), for reducing use, treating opioid use disorder (OUD), and preventing overdoses, yet its utilization remains insufficient compared to the growing crisis. 3 – 5 MOUD includes Buprenorphine, Naloxone, Buprenorphine plus Naloxone, Methadone, and Naltrexone. 3 , 5 Despite its proven effectiveness in reducing opioid use and preventing overdose deaths, MOUD remains underutilized in substance use disorder treatment (SUDT) settings. 6 – 8 This study adopts an implementation science approach to explore factors influencing the implementation of MOUD in SUDT facilities in California. Guided by the Exploration, Preparation, Implementation, Sustainability (EPIS) Framework, the study focuses on two key EPIS constructs during the Sustainment Phase, bridging factors and the outer context, to understand the implementation of MOUD in SUDT. 9 – 12 Bridging factors are factors that are interrelated between the organization and the outer environment and the outer context is the external environment in relation to an organization. In this study, bridging factors reflect the type of organization that operates the facility, such as private for-profit, private non-profit, and government-owned, and if the facility is accredited. 13 The outer context reflects SUDT facility funding sources, such as what insurance types they accept and if they receive government funding or grants. Past research focuses more on publicly funded or community-based organizations and suggests they are more likely to implement evidence based practices (EBPs), but only 25% of community-based services provide EBPs, including addiction medications. 9 , 14 , 15 Studies have found that only about 23% of publicly funded SUDT facilities offered MOUD. 16 , 17 While privately owned SUDT facilities are more likely to offer MOUD, less than half had physicians who prescribed the medications. 16 , 17 Additionally, there has been a steady decline in the number of publicly owned SUDT facilities, but an increase in private, for-profit facilities, potentially contributing to disparities in access to treatment. 17 When it comes to the adoption of MOUD in SUDT facilities, studies have found that naltrexone, which was FDA approved in 1994, is estimated to be adopted in around 1 in 5 facilities. 18 The adoption of naltrexone is lower in public non-profit centers compared to private for-profit or private non-profit facilities. 18 Buprenorphine was FDA approved in 2002, and in 2004 about 14% of facilities had adopted it, with rates being higher in private facilities than public ones. 18 Organizational factors related to higher adoption of buprenorphine have been being for-profit, being accredited, offering detox, and using naltrexone. 6 , 18 , 19 However, some studies have mixed results on whether being for-profit and having accreditation are significantly associated with the adoption of buprenorphine. 18 , 20 , 21 Accreditation, given by a regulatory authority, is an important program and quality assessment tool for EBPs that supports consistency and reliability of services . 22 , 23 Accreditation, licensure, and credentialing can also help facilities obtain federal and state funding, such as using Medicaid and Medicare. 22 Privately owned facilities are more likely to be accredited, and this has been linked to having more resources and services. 22 , 24 In two different national studies using 2017 treatment data, accredited residential facilities were more likely to offer MOUD. 24 , 25 Accreditation, recognized as a bridging factor, helps connect internal and external contexts during the implementation and sustainment phases of EPIS, facilitating the delivery and continuity of MOUD. 13 , 15 The outer context also significantly impacts MOUD availability, which is associated with program funding, ownership, and insurance. 26 In January 2014, the Medicaid expansion of the Patient Protection and Affordable Care Act of 2010 (ACA) was implemented to help increase access to SUDT. 27 States like California that incorporated Medicaid expansion saw an increase in buprenorphine prescriptions paid through Medicaid. California also implemented the Drug Medi-Cal Organized Delivery System (DMC-ODS), which intended to make substance use treatment, like MOUD, more accessible and evidence-based, while expanding Medicaid care. 28 Medicaid expansions and coverage of medications are found to increase the availability of MOUD. 26 Private insurance is the most common source of payment for MOUD, but public insurance also plays an important role, with Medicaid recipients being more likely to receive MOUD. 27 , 29 In summary, the EPIS Framework highlights the importance of organizational factors (bridging factors) and external funding structures (outer context) in the implementation and sustainment of MOUD in SUDT facilities. This study hypothesizes that for-profit, accredited facilities and those accepting private insurance, government funding, and Medicaid will be more likely to offer MOUD. By understanding these implementation factors, the study aims to inform strategies that could improve the availability and utilization of MOUD, ultimately contributing to better treatment outcomes for individuals with OUD. METHODS This study used data from the 2019 National Survey of Substance Abuse Treatment Services (N-SSATS), an annual survey of U.S. SUDT facilities that is nationally representative. 30 Data were collected between March and December 2019, with 15,961 of 17,808 eligible facilities responding, and 1,797 California facilities were included in this study. Facilities excluded were those that did not provide substance use treatment, such as halfway houses, solo practitioners, or jails. The survey’s item-response rate was about 99%. 30 To assess if facilities offered MOUD, a dichotomous variable was created, called MOUD sustainment, with yes being if they offer any of the following medications: Methadone, Naltrexone (oral), Naltrexone (extended-release, injectable), buprenorphine with naloxone, buprenorphine without naloxone, buprenorphine sub-dermal implant, buprenorphine (extended-release, injectable). Independent variables were based on the EPIS constructs of bridging factors and the outer context. Bridging variables consisted of the organization that operates the facility, a mutually exclusive categorical variable consisting of private for-profit organization; private non-profit organization; state government; local, county, or community government; tribal government; federal government. This variable was recoded bycombining all government-run entities, leading to facilities being categorized as private for-profit, private non-profit, or government-owned. Accreditation status was also a bridging factor variable. Outer context factors examined included funding, categorized by the types of payment accepted (cash, private health insurance, Medicaid, Medicare, state-financed insurance, federal military insurance, and IHS/Tribal/Urban funds) and whether the facility received government funding. Types of payment were not mutually exclusive. Missing data were assessed, and chi-square analyses showed that missing data was not random, with significant differences in missing responses from 19 facilities, mostly private non-profits that did not offer MOUD. These facilities were excluded from the analysis. A sensitivity analysis confirmed no significant difference when they were included. Statistical analyses were conducted in SPSS Version 28, with descriptive statistics, chi-square tests for differences in funding and accreditation by facility type, and multiple logistic regressions to determine predictors of offering MOUD. 31 All variables were tested for multicollinearity with variables having a correlation coefficient of 0.80 not being maintained. 32 None of the variables were correlated over 0.80. For chi-square tests, post-hoc tests were conducted on significant results to see which facility was significant. This was done by looking at the adjusted residual and using the Bonferroni Correction method to adjust for Type 1 errors, with the alpha being set at .0167. For logistic regressions, an alpha level of p < .05 was deemed significant. RESULTS Table 1 will go here. Table 1 Descriptive Statistics of MOUD Offered Private for-profit org 777 (43.7%) Private non-profit org 796 (44.8%) Government Owned 205 (11.5%) Medically Assisted Treatment Type N(%) Methadone 146 (18.8%) 48 (6.0%) 15 (7.2%) 209 (11.8%) Buprenorphine 392 (50.5%) 102 (12.8%) 32 (15.6%) 526 (29.6%) Buprenorphine with naloxone 502 (64.6%) 163 (20.5%) 52 (25.4%) 717 (40.3%) Buprenorphine Sub-dermal implant 90 (11.6%) 20 (2.5%) 2 (1.0%) 112 (6.3%) Buprenorphine (extended-release, injectable) 196 (25.2%) 32 (4.0%) 10 (4.9%) 238 (13.4%) Naltrexone (oral) 464 (59.7%) 125 (15.7%) 55 (26.8%) 644 (36.2%) Naltrexone (extended-release injectable) 403 (51.9%) 124 (15.6%) 51 (24.9%) 578 (32.5%) MOUD Offered at Facility 585 (75.3%) 198 (24.9%) 65 (31.7%) 848 (47.7%) Table 1 shows the different types of MOUD offered. The MOUD offered the most were Buprenorphine with naloxone, Naloxone (oral), and Naloxone (injectable). Overall, 47.7% of facilities were found to offer any sort of MOUD, with 75.3% of private for-profit facilities offering MOUD. When it came to ownership type, 24.9% of private non-profit facilities offered MOUD, and 31.7% of government-owned facilitiesoffered MOUD. Table 2 will go here. Table 2 Descriptive Statistics of Independent Variables Bridging Factor Variables n (%) Organization that Operates the Facility Private For-Profit 777 (43.7%) Private Non-Profit 796 (44.8%) Government Owned 205 (11.5%) Facility is licensed, certified, or accredited to provide substance use services Yes 963 (54.2%) No 813 (45.8%) Outer Context Variables n (%) Cash or self-payment Yes 1511 (85.0%) No 267 (15.0%) Private health insurance Yes 1130 (63.6%) No 648 (36.4%) Medicaid Yes 685 (38.5%) No 1093 (61.5%) Medicare Yes 362 (20.4%) No 1416 (79.6%) State-financed health insurance plan other than Medicaid Yes 432 (24.3%) No 1346 (75.7%) Federal military insurance Yes 391 (22.0%) No 1387 (78.0%) IHS/Tribal/Urban funds Yes 291 (16.4%) No 1487 (83.6%) Facility receives funding from the government Yes 782 (45.9%) No 922 (53.7%) A total of 1,778 facilitates from California were included in the 2019 N-SSATS data. The breakdown of the organization that operates the facility can be seen in Table 2 . When looking at ownership type, 43.7% of facilities were private for-profit organizations, 44.8% were private non-profit organizations, and 11.5% were government owned. More than half (54.2%) of facilities were accredited. The most accepted payment types were cash or self-pay (85.0%), and private insurance (63.6%). Only 38.5% of SUDT facilities accepted Medicaid, and all other insurances were accepted at 16%-25% of facilities. In total, 45.9% (N = 782) of California facilities receive funding from the government to support their substance use treatment programs. Table 3 will go here. Table 3 Type of Funding Source Accepted by Type of Operating Organization Accepted Funding Private for-profit org Private non-profit org Government Chi-Square (p-value) Facility receives funding from the government 57 (7.5%) 542 (72.3%) 183 (92.4%) 830.58 (< .001) Cash or self-payment 759 (97.7%) 623 (78.3%) 129 (62.9%) 204.49 (< .001) Private health insurance 713 (91.8%) 328 (41.2%) 89 (43.4%) 474.47 (< .001) Medicaid 128 (16.5%) 424 (53.3%) 133 (64.9%) 292.68 (< .001) Medicare 59 (7.6%) 220 (27.6%) 83 (40.5%) 155.33 (< .001) State-financed health insurance plan other than Medicaid 123 (15.8%) 227 (28.5%) 82 (40.0%) 65.48 (< .001) Federal military insurance 263 (33.8%) 83 (10.4%) 45 (22.0%) 125.73 (< .001) IHS/Tribal/Urban funds 171 (22.0%) 91 (11.4%) 29 (14.1%) 32.96 (< .001) Facility is licensed, certified, or accredited to provide substance use services 633 (81.6%) 286 (35.4%) 50 (24.0%) 424.71 (< .001) Table 3 presents the percentage of facilities that accepted funding types and the chi-square results of the relationships between funding types and the organization that operates the facility. Receiving funding from the government was statistically significant in association with the organization that operates the facility ( X 2 (2, 1704) = 838.04, p < .001). Most facilities that are government-owned receive funding from the government (92.4%). Only 57 (7.5%) private for-profit facilities received government funding. There was a statistically significant difference in accepting cash or self-payment ( X 2 (2, 1778) = 204.49, p < .001). In terms of directionality, there seems to be an association between the operating organization and accepted funding, as a significantly higher percentage of private for-profit facilities (97.7%) accepted cash or self-payment, relative to private non-profit (78.3%), and government-owned facilities (62.9%). There was also a statistically significant difference in accepting private health insurance ( X 2 (2, 1778) = 474.47, p < .001), military insurance ( X 2 (2, 1778) = 125.73, p < .001) and tribal insurance ( X 2 (2, 1778) = 32.96, p < .001), with private for-profit facilities having higher percentages of accepting them compared to private non-profit and government-owned facilities. Additionally, there was a statistically significant difference in being accredited and facility type ( X 2 (2, 1776) = 427.02, p < .001), with a higher percentage of for-profit facilities (81.7%) being accredited compared to 35.4% of private non-profit and 23.4% government-owned facilities. There was a statistically significant association in accepting Medicaid ( X 2 (2, 1778) = 292.68, p < .001), Medicare ( X 2 (2, 1778) 155.33, p < .001), and other state-financed insurance ( X 2 (2, 1778) 65.48, p < .001) and operating organization type. A higher percentage of government-owned facilities (64.9%) accepted Medicaid, relative to private for-profit facilities (16.5%) and private non-profit facilities (53.3%). Government-owned facilities (40.5%) also accepted Medicare at a higher rate compared to private for-profit facilities (7.6%) and private non-profit facilities (28.5%). Lastly, government-owned facilities (40.0%) accepted other state-financed insurances at a higher rate than private for-profit facilities (15.8%) and private non-profit facilities (28.5%). Table 4 will go here. Table 4 Type of Funding Source Accepted by Accreditation Accepted Funding Not Accredited Accredited Chi-Square (p-value) Facility receives funding from the government 517 (66.1%) 265 (33.9%) 254.39 (< .001) Cash or self-payment 630 (77.5%) 879 (91.3%) 65.59 (< .001) Private health insurance 288 (35.4%) 841(87.3%) 512.88 (< .001) Medicaid 378 (46.5%) 307 (31.9%) 39.74 (< .001) Medicare 226 (27.8%) 136 (14.1%) 50.81 (< .001) State-financed health insurance plan other than Medicaid 219 (26.9%) 213 (22.1%) 5.56 (.018) Federal military insurance 81 (10.0%) 310 (32.2%) 126.86 (< .001) IHS/Tribal/Urban funds 97 (11.9%) 194 (20.1%) 21.71 (< .001) Table 4 presents the percentages of organizations having accreditation or not and what funding they receive, along with the chi-square results of the relationships. Facilities that were accredited were more likely to accept cash or self-payment ( X 2 (2, 1776) 65.59, p < .001), private health insurance ( X 2 (2, 1776) 512.88, p < .001), federal military insurance ( X 2 (2, 1776) 126.86, p < .001), and IHS/Tribal/Urban funds ( X 2 (2, 1776) 21.71, p < .001). Facilities that were not accredited were more likely to receive government funding ( X 2 (2, 1702) 254.39, p < .001), Medicaid ( X 2 (2, 1776) 39.74, p < .001), and Medicare ( X 2 (2, 1776) 50.81, p < .001). Table 5 will go here. Table 5 Unadjusted and Adjusted Multiple Logistic Regressions of SUD Facility Characteristics Associated offering MAUD and MOUD MOUD Offered Unadjusted Odds Ratio Adjusted Odds Ratio Odds Ratio Confidence Interval Odds Ratio Confidence Interval Organization that operates the facility Private for-profit org (Ref) (Ref) Private non-profit org 0.11** 0.09, 0.14 0.67 0.40, 1.12 Government Owned 0.15** 0.11, 0.21 0.33** 0.23, 0.47 Facility is accredited to provide substance abuse services 11.60** 9.23, 14.53 5.23** 3.97, 6.90 Accepted Payment Types Cash or self-payment 3.05** 2.28, 4.10 0.84 0.56, 1.27 Private health insurance 11.63** 9.05, 14.93 2.96** 2.10, 4.16 Medicaid 0.49** 0.40, 0.59 1.07 0.79, 1.45 Medicare 0.61** 0.48, 0.78 1.17 0.82, 1.65 State-financed health insurance 0.91 .073, 1.13 1.02 0.75, 1.41 Federal military insurance 4.00** 3.12, 5.12 1.28 0.93, 1.76 IHS/Tribal/Urban funds 2.55** 1.96, 3.32 1.49* 1.05, 2.12 Facility receives funding from the government 0.19** 0.16, 0.24 0.69* 0.48, 0.98 *Significant at < .05 **Significant at < .001 Table 5 shows the unadjusted and adjusted results of logistic regressions of all independent variables and if they are associated with whether the facilities offer MOUD. In the adjusted analysis, government-owned facilities (AOR: 0.33; 95% CI: 0.23, 0.47) had lower odds of offering MOUD when compared to private for-profit organizations, meaning that private for-profit facilities are about three times more likely to offer MOUD than those that are government-owned. Private non-profit organizations had lower odds of offering MOUD (OR: 0.11; 95% CI: 0.09, 0.14) compared to private for-profit organizations in the bivariate logistic regression, but this was no longer significant in the adjusted model (AOR: 0.67; 95% CI: 0.40, 1.12). Facilities that had accreditations were over 5 times more likely to offer MOUD than those that were not (AOR: 5.23; 95% CI: 3.97, 6.90) Facilities that accepted private health insurance were almost 3 times more likely to offer MOUD (AOR: 2.96; 95% CI: 2.10, 4.16) and facilities that accept IHS/Tribal/Urban funds were almost 1.5 times more likely to offer MOUD (AOR: 1.49; 95% CI: 1.05, 2.12). Facilities receiving funding from the government to support their substance use program showed lower odds of offering MOUD (AOR: 0.69; 95% CI: 0.48, 0.98), or facilities that don’t receive funding from the government are 1.45 times more likely to offer MOUD. In the bivariate logistic regression, accepting Medicaid was associated with lower odds of offering MOUD (OR: 0.49; 95% CI: 0.40, 0.59), but this relationship was no longer significant in the adjusted model (AOR: 1.07; 95% CI: 0.79, 1.45). DISCUSSION Guided by the EPIS Framework, this study examined the implementation factors related to the sustainment of MOUD in SUDT facilities in California. In 2019, only 47.4% of Californian facilities offered any type of MOUD. Key findings identified bridging factors, such as accreditation and the organization that operates a facility, that were associated with a significantly higher likelihood of offering MOUD. Having accreditation was associated with being five times more likely to offer MOUD. When compared to private for-profit organizations, government-owned organizations are less likely to offer MOUD. When it came to the outer context element of funding, facilities that accepted private health insurance and IHS/Tribal/Urban funds were more likely to offer MOUD, while facilities receiving grant money were less likely to offer MOUD. To our knowledge, this is one of the first studies to apply the EPIS Framework to assess MOUD implementation and sustainment in SUDT facilities in California, with a specific focus on bridging factors, which are often left out in implementation studies. 13 Our findings suggest that bridging factors, including the organization type and accreditation, can connect facilities from the outer context of funding, such as how the organization that operates the facility or accreditation is connected to funding sources and how these factors help the implementation and sustainment of EBPs. 33 For example, private for-profit and accredited facilities were more likely to accept private and tribal insurance, which were associated with higher odds of offering MOUD. Policymakers could utilize these findings to promote accreditation accessibility and encourage facilities to accept different insurance types to improve MOUD delivery and sustainment. Accredited facilities were over five times more likely to offer MOUD than those that were not, which aligns with past research. 17 , 24 , 25 , 34 , 35 Facilities that are accredited have been found to sustain the use of MOUDs longer than those without accreditation. 34 Implementation of MOUD may be higher in accredited facilities as they are part of a social network of other SUDT facilities that creates pressure and accountability to use up-to-date EBPs. 35 However, accreditation is costly and may not be viable for public organizations that operate within a smaller budget. 36 Future policies could offer financial incentives to make accreditation more accessible to government-owned facilities. However, it’s important to note that accreditation does not necessarily correlate with better patient outcomes, as some accredited facilities may have lower patient experience scores. 36 SUDT facilities with accreditation have been found to offer admission to potential patients without doing a complete clinical evaluation. 37 If accreditation becomes the standard for SUDT, further quality control of what accrediting bodies are assessing will need to be more transparent to ensure that MOUD is being offered in facilities and actually being utilized to sustain the use of MOUD. As this study found, SUDT programs that are privately owned are more likely to hold accreditation, both of which are related to a higher quality of care and can further disadvantage those who do not have the means to access treatment. 22 In recent years, there has been an increase in private for-profit facilities and a decrease in publicly owned ones. 17 For-profit programs can be costly, with some asking for over $ 17,000 to be admitted into treatment, which is higher than the average person with an opioid use disorder can afford. 37 Furthermore, private for-profit and accredited facilities are more likely to offer MOUD. This could be because for-profit facilities have more financial means to be innovative and adopt new practices. 35 To keep up with treatment costs, for-profit agencies might have to keep up with EBPs and treatment options to entice patients to come to services. 35 Although these facilities are more likely to offer MOUD, research has shown that only a small percentage of patients in such facilities receive the treatment. 38 Therefore, there may be a discrepancy between facilities offering MOUD and patients receiving it. Future studies should explore the disconnect between facilities offering MOUD and patients’ ability to access it due to financial constraints, attitudes toward MOUD, or insurance type. California SUDT facilities primarily consist of private for-profit and non-profit organizations, with over 60 percent accepting private insurance and less than 40 percent accepting Medicaid. Facilities taking private insurance were more likely to offer MOUD. The number of facilities accepting Medicaid is low (38.5%), considering California has the most extensive Medicaid program in the United States. 39 Contradictory to our findings, Medicaid expansions, and coverage of medications have been found to increase the availability of MOUD. 26 With California participating in these Medicaid expansions and having the largest Medicaid program, we expected to see Medicaid as an implementation factor related to offering MOUD, which was not the case. In past studies, insurance was the most crucial element in being on MOUD, with people on public insurance being more likely to be on MOUD than those with private insurance. 29 This could be due to Medicaid programs often requiring prior authorization for medications, which is associated with lower odds of offering MOUD. 26 It could also be that more for-profit facilities offer MOUD, but that MOUD is more accessible to those with public insurance. This disconnect could not be assessed with this data as we were unable to see the percentage of patients who received MOUD. If Medicaid is an enabling factor in being on MOUD, then further policy changes could focus on encouraging SUDT facilities to take Medicaid, whether by increasing reimbursement rates or offering other incentives to accept this insurance type. Lastly, government funding is a factor that facilitates the implementation of certain EBPs. 14 While government-owned facilities were more likely to receive government funding, they were less likely to offer MOUD. Most government-owned facilities received government funding. If the organization that operates a facility is a bridging factor between the outer and inner contexts, then this suggests that funding is related to the type of facility and can affect the type of EBPs that are being offered. Future policies could focus on requiring government-owned facilities to implement more EBPs and to obtain accreditation that ensures these practices are followed. Changes in government funding could provide funding to facilities if they use MOUD, which may help increase the availability of MOUD in SUDT facilities. This study had limitations, including the exclusion of solo practitioners and primary care physicians who may also provide MOUD. This means other entities may provide SUDT that do not fall under the SUDT facilities umbrella of the study, and more options may be available for people who want MOUD. Additionally, the N-SSATS dataset did not capture information about the number of physicians who could prescribe MOUD at the SUDT facilities, which could impact the delivery of these treatments. Future studies should address these gaps to better understand the barriers to MOUD access and improve its delivery across different settings. CONCLUSION To our knowledge, this is the first study to use the EPIS framework to understand implementation factors that are associated with the sustainment of MOUD. To better meet the needs of people with substance use disorders, implementation efforts must be concentrated on evidence-based practices, especially medication-assisted therapies. This study's findings suggest that policy interventions focused on accreditation, funding models, and insurance acceptance could be key strategies to improve the delivery and sustainment of MOUD in SUDT facilities. Efforts to make accreditation more accessible and encourage facilities to accept diverse forms of insurance, and increasing reimbursement rates for Medicaid, may help increase MOUD access, providing a more effective means of combating the opioid epidemic. Future studies could concentrate on how policies like the DMC-ODS and Medicaid expansion are increasing the accessibility of MOUD and clarifying if Medicaid is an enabling factor of being on MOUD. Lastly, future policy changes can focus on the push for utilizing MOUD as an EBP for treating opioid use disorders and encouraging their use in SUDT facilities. Abbreviations Medication for opioid use disorders (MOUD) Substance use disorder treatment (SUDT) National Survey of Substance Abuse Treatment Services (N-SSATS) Food and Drug Administration (FDA) American Society of Addiction Medicine (ASAM) World Health Organization (WHO) Opioid use disorder (OUD) Exploration, Preparation, Implementation, Sustainability (EPIS) Framework Evidence based practices (EBPs), Affordable Care Act of 2010 (ACA) Drug Medi-Cal Organized Delivery System (DMC-ODS), Declarations Ethics approval and consent to participate: This research was IRB exempt due to being secondary data that was publicly available. Consent for publication: Not applicable Availability of data and materials: The data that support the findings of this study are available from SAMHSA repository, and available at: https://www.samhsa.gov/data/report/national-survey-substance-abuse-treatment-services-n-ssats-2019-data-substance-abuse. 30 Competing interests: The authors declare that they have no competing interests Funding: No funding was used for this research. Authors' contributions: MN and LRS analyzed and interpreted the data. MN was a major contributor in writing the manuscript. AW and LAU provided feedback on the manuscript. All authors read and approved the final manuscript. Acknowledgements MJN would like to acknowledge her dissertation committee from the Joint Doctoral Program in Interdisciplinary Research and Substance Use and San Diego State University and University of California San Diego who helped her through this process. This research had no funding support. 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Updated January 4, 2022. https://drugabuse.com/treatment/medications/ . Accessed April 23, 2022. Yang JC, Roman-Urrestarazu A, Brayne C. Responses among substance abuse treatment providers to the opioid epidemic in the USA: Variations in buprenorphine and methadone treatment by geography, operational, and payment characteristics, 2007-16. PLoS ONE. 2020;15(3):e0229787. 10.1371/journal.pone.0229787 . Published 2020 Mar 3. Knudsen HK, Lofwall MR, Walsh SL, Havens JR, Studts JL. Physicians' decision-making when implementing buprenorphine with new patients: Conjoint analyses of data from a cohort of current prescribers. J Addict Med. 2018;12(1):31–9. 10.1097/ADM.0000000000000360 . Jones CM, Campopiano M, Baldwin G, et al. National and state treatment need and capacity for opioid agonist medication-assisted treatment. Am J Public Health. 2015;105:e55–63. 10.2105/AJPH.2015.302664 . Moullin JC, Dickson KS, Stadnick NA, Rabin B, Aarons GA. Systematic review of the Exploration, Preparation, Implementation, Sustainment (EPIS) framework. Implement Sci . 2019;14(1):1. Published 2019 Jan 5. 10.1186/s13012-018-0842-6 Aarons GA, Hurlburt M, Horwitz SM. Advancing a conceptual model of evidence-based practice implementation in public service sectors. Adm Policy Ment Health. 2011;38(1):4–23. 10.1007/s10488-010-0327-7 . EPIS Framework. https://episframework.com. Accessed on May 18, 2021. Greene MC, Kane JC, Khoshnood K, Ventevogel P, Tol WA. Challenges and opportunities for implementation of substance misuse interventions in conflict-affected populations. Harm Reduct J. 2018;15:58. https://doi.org/10.1186/s12954-018-0267-1 . Lengnick-Hall R, Stadnick NA, Dickson KS, Moullin JC, Aarons GA. Forms and functions of bridging factors: specifying the dynamic links between outer and inner contexts during implementation and sustainment. Implement Sci . 2021;16(1):34. Published 2021 Apr 1. 10.1186/s13012-021-01099-y Lash SJ, Timko C, Curran GM, McKay JR, Burden JL. Implementation of evidence-based substance use disorder continuing care interventions. Psychol Addict Behav. 2011;25(2):238–51. 10.1037/a0022608 . Louie E, Barret EL, Baillie A, Haber P, Morley KC. Implementation of evidence-based practice for alcohol and substance use disorders: Protocol for systematic review. Syst Reviews 2020:925). Medication-assisted treatment improves outcomes for patients with opioid use disorder. PEW. Updated November 22. 2016. https://www.pewtrusts.org/en/research-and-analysis/fact-sheets/2016/11/medication-assisted-treatment-improves-outcomes-for-patients-with-opioid-use-disorder . Accessed April 28, 2022. Knudsen HK, Roman PM, Oser CB. Facilitating factors and barriers to the use of medications in publicly funded addiction treatment organizations. J Addict Med. 2010;4(2):99–107. 10.1097/ADM.0b013e3181b41a32 . Garner BR. Research on the diffusion of evidence-based treatments within substance abuse treatment: a systematic review. J Subst Abuse Treat. 2009;36(4):376–99. 10.1016/j.jsat.2008.08.004 . Epub 2008 Nov 12. PMID: 19008068; PMCID: PMC2695403. Mojtabai R, Mauro C, Wall MM, Barry CL, Olfson M. Medication treatment for opioid use disorders in substance use treatment facilities. Health Aff (Millwood). 2019;38(1):14–23. 10.1377/hlthaff.2018.05162 . PMID: 30615514; PMCID: PMC6816341. Knudsen HK, Ducharme LJ, Roman PM. Early adoption of buprenorphine in substance abuse treatment centers: Data from the private and public sectors. J Subst Abuse Treat. 2006;30:363–73. [PubMed: 16716852]. Ducharme LJ, Knudsen HK, Roman PM, Johnson JA. Innovation adoption in substance abuse treatment: Exposure, trialability, and the Clinical Trials Network. J Subst Abuse Treat. 2007;32(4):331–40. [PubMed: 17481456]. Archibald ME, Rankin CP. Community context and healthcare quality: the impact of community resources on licensing and accreditation of substance abuse treatment agencies. J Behav Health Serv Res. 2013;40(4):442 – 56. 10.1007/s11414-013-9340-4 . PMID: 23666273. Wells R, Lemak CH, Alexander JA, et al. Do licensing and accreditation matter in outpatient substance abuse treatment programs. J Subst Abuse Treat. 2007;33:43–50. Huhn AS, Hobelmann JG, Strickland JC, et al. Differences in availability and use of medications for opioid use disorder in residential treatment settings in the United States. JAMA Netw Open. 2020;3(2):e1920843. 10.1001/jamanetworkopen.2019.20843 . PMID: 32031650; PMCID: PMC8188643. Alinsky RH, Hadland SE, Matson PA, Cerda M, Saloner B. Adolescent-serving addiction treatment facilities in the United States and the availability of medications for opioid use disorder. J Adolesc Health. 2020;67(4):542–9. 10.1016/j.jadohealth.2020.03.005 . Epub 2020 Apr 24. PMID: 32336560; PMCID: PMC7508760. Abraham AJ, Andrews CM, Harris SJ, Friedmann PD. Availability of medications for the treatment of alcohol and opioid use disorder in the USA. Neurotherapeutics. 2020;17(1):55–69. 10.1007/s13311-019-00814-4 . Olfson M, Zhang VS, King M, Mojtabai R. Changes in buprenorphine treatment after medicaid expansion. Psychiatr Serv. 2021;72(6):633–40. 10.1176/appi.ps.202000491 . Epub 2021 Mar 18. PMID: 33730878; PMCID: PMC9097622. Drug Medi-Cal Organized Delivery System. California Department of Health Care Services, Updated. April 21, 2022. https://www.dhcs.ca.gov/provgovpart/Pages/Drug-Medi-Cal-Organized-Delivery-System.aspx . Accessed April 23, 2022. Mauro PM, Gutkind S, Annunziato EM, Samples H. Use of medication for opioid use disorder among US adolescents and adults with need for opioid treatment, 2019. JAMA Netw Open . 2022;5(3):e223821. Published 2022 Mar 1. 10.1001/jamanetworkopen.2022.3821 Substance Abuse and Mental Health Services Administration. National Survey of Substance Abuse Treatment Services (N-SSATS): 2019. Data on Substance Abuse Treatment Facilities . Rockville, MD: Substance Abuse and Mental Health Services Administration, 2020. https://www.samhsa.gov/data/report/national-survey-substance-abuse-treatment-services-n-ssats-2019-data-substance-abuse . Accessed April 1, 2022. IBM Corp. IBM SPSS Statistics for Macintosh , Version 28.0. Armonk, NY: IBM Corp; Released 2021. Bannon WM. The 7 steps of data analysis: A manual for conducting a quantitative research study. New York: StatsWhisperer; 2013. Lengnick-Hall R, Willging C, Hurlburt M, Fenwick K, Aarons GA. Contracting as a bridging factor linking outer and inner contexts during EBP implementation and sustainment: a prospective study across multiple U.S. public sector service systems. Implement Sci . 2020;15(1):43. Published 2020 Jun 11. 10.1186/s13012-020-00999-9 Heinrich CJ, Cummings GR. Adoption and diffusion of evidence-based addiction medications in substance abuse treatment. Health Serv Res. 2014;49(1):127–52. 10.1111/1475-6773.12093 . Epub 2013 Jul 16. PMID: 23855719; PMCID: PMC3922470. Oser CB, Roman PM. Organizational-level predictors of adoption across time: naltrexone in private substance-use disorders treatment centers. J Stud Alcohol Drugs. 2007;68(6):852–61. 10.15288/jsad.2007.68.852 . PMID: 17960303; PMCID: PMC4267569.—appears at the end. Jha AK. Accreditation, Quality, and Making Hospital Care Better. JAMA. 2018;320(23):2410–1. 10.1001/jama.2018.18810 . Beetham T, Saloner B, Gaye M, et al. Admission practices and cost of care for opioid use disorder at residential addiction treatment programs in the US. Health Aff (Millwood). 2021;40(2):317–25. 10.1377/hlthaff.2020.00378 . Nosyk B, Li L, Evans E, et al. Utilization and outcomes of detoxification and maintenance treatment for opioid dependence in publicly-funded facilities in California, USA: 1991–2012. Drug Alcohol Depend. 2014;143:149–57. Norris L. California and the ACA’s Medicaid expansion. Healthinsurance.org. January 26, 2022. https://www.healthinsurance.org/medicaid/california/ . Accessed August 29, 2022. Additional Declarations No competing interests reported. Cite Share Download PDF Status: Under Revision Version 1 posted Editorial decision: Revision requested 04 Apr, 2026 Reviews received at journal 19 Dec, 2025 Reviewers agreed at journal 27 Oct, 2025 Reviewers agreed at journal 26 Oct, 2025 Reviewers agreed at journal 29 Apr, 2025 Reviewers invited by journal 27 Apr, 2025 Editor assigned by journal 28 Mar, 2025 Submission checks completed at journal 28 Mar, 2025 First submitted to journal 25 Mar, 2025 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-6307033","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":449139784,"identity":"4bbb9ae0-29b3-441f-9887-d01c43f89f0d","order_by":0,"name":"Melanie J Nicholls","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAAv0lEQVRIiWNgGAWjYFACxgZmBgYLGQb2BgYJsMAB4rRI8DDwHCBaCwMDRItEApFadGc3N34uqJDgkZ/5/OHNn20Mcnw3EvBrMbtzsFl6xhkJHoPbOcbWvG0MxpIEtdxIbGPmbQNqkc5hk2ZsY0jcQLQW+ZnHn0kCHVZPvBaGGwxmEkCHJRgQoaVZmgfklzNAv/CckzCceeYBIS3pDz/zVNjIybcff3jzR5mNPN9xAragAwnSlI+CUTAKRsEowA4AeW5APNrWlgYAAAAASUVORK5CYII=","orcid":"","institution":"San Diego State University","correspondingAuthor":true,"prefix":"","firstName":"Melanie","middleName":"J","lastName":"Nicholls","suffix":""},{"id":449139785,"identity":"af13f506-bff5-4dd1-9d91-f37d20b482f8","order_by":1,"name":"Ashley Weitensteiner","email":"","orcid":"","institution":"San Diego State University","correspondingAuthor":false,"prefix":"","firstName":"Ashley","middleName":"","lastName":"Weitensteiner","suffix":""},{"id":449139786,"identity":"c619c1ee-71c9-4352-89af-3f8ca1a93b59","order_by":2,"name":"Laramie R Smith","email":"","orcid":"","institution":"University of California, San Diego","correspondingAuthor":false,"prefix":"","firstName":"Laramie","middleName":"R","lastName":"Smith","suffix":""},{"id":449139787,"identity":"34154040-0156-4758-bcae-237a255cfe9c","order_by":3,"name":"Lianne A Urada","email":"","orcid":"","institution":"San Diego State University","correspondingAuthor":false,"prefix":"","firstName":"Lianne","middleName":"A","lastName":"Urada","suffix":""}],"badges":[],"createdAt":"2025-03-25 22:53:06","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-6307033/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-6307033/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":81644635,"identity":"56384f00-60af-4467-94d6-e6d2662c041e","added_by":"auto","created_at":"2025-04-29 14:19:36","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":953813,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-6307033/v1/58b56196-6feb-42d2-8599-15cde81289c0.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"California Substance Use Disorder Treatment Facility Characteristics Associated with Offering Medications for Opioid Use Disorder","fulltext":[{"header":"INTRODUCTION","content":"\u003cp\u003eThe opioid epidemic in the United States has worsened with the ever-increasing accessibility of fentanyl, with overdose deaths involving opioids rising from 49,860 in 2019 to 81,806 in 2022.\u003csup\u003e\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e,\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e\u003c/sup\u003e Medication for opioid use disorder (MOUD) is considered the gold standard by leading organizations such as the Food and Drug Administration (FDA), American Society of Addiction Medicine (ASAM) and the World Health Organization (WHO), for reducing use, treating opioid use disorder (OUD), and preventing overdoses, yet its utilization remains insufficient compared to the growing crisis.\u003csup\u003e\u003cspan additionalcitationids=\"CR4\" citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e\u003c/sup\u003e MOUD includes Buprenorphine, Naloxone, Buprenorphine plus Naloxone, Methadone, and Naltrexone.\u003csup\u003e\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e,\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e\u003c/sup\u003e Despite its proven effectiveness in reducing opioid use and preventing overdose deaths, MOUD remains underutilized in substance use disorder treatment (SUDT) settings.\u003csup\u003e\u003cspan additionalcitationids=\"CR7\" citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e \u003cp\u003eThis study adopts an implementation science approach to explore factors influencing the implementation of MOUD in SUDT facilities in California. Guided by the Exploration, Preparation, Implementation, Sustainability (EPIS) Framework, the study focuses on two key EPIS constructs during the Sustainment Phase, bridging factors and the outer context, to understand the implementation of MOUD in SUDT.\u003csup\u003e\u003cspan additionalcitationids=\"CR10 CR11\" citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e\u003c/sup\u003e Bridging factors are factors that are interrelated between the organization and the outer environment and the outer context is the external environment in relation to an organization. In this study, bridging factors reflect the type of organization that operates the facility, such as private for-profit, private non-profit, and government-owned, and if the facility is accredited.\u003csup\u003e\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e\u003c/sup\u003e The outer context reflects SUDT facility funding sources, such as what insurance types they accept and if they receive government funding or grants.\u003c/p\u003e \u003cp\u003ePast research focuses more on publicly funded or community-based organizations and suggests they are more likely to implement evidence based practices (EBPs), but only 25% of community-based services provide EBPs, including addiction medications.\u003csup\u003e\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e,\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e,\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e\u003c/sup\u003e Studies have found that only about 23% of publicly funded SUDT facilities offered MOUD.\u003csup\u003e\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e,\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e\u003c/sup\u003e While privately owned SUDT facilities are more likely to offer MOUD, less than half had physicians who prescribed the medications.\u003csup\u003e\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e,\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e\u003c/sup\u003e Additionally, there has been a steady decline in the number of publicly owned SUDT facilities, but an increase in private, for-profit facilities, potentially contributing to disparities in access to treatment.\u003csup\u003e\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e \u003cp\u003eWhen it comes to the adoption of MOUD in SUDT facilities, studies have found that naltrexone, which was FDA approved in 1994, is estimated to be adopted in around 1 in 5 facilities.\u003csup\u003e\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e\u003c/sup\u003e The adoption of naltrexone is lower in public non-profit centers compared to private for-profit or private non-profit facilities.\u003csup\u003e\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e\u003c/sup\u003e Buprenorphine was FDA approved in 2002, and in 2004 about 14% of facilities had adopted it, with rates being higher in private facilities than public ones.\u003csup\u003e\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e\u003c/sup\u003e Organizational factors related to higher adoption of buprenorphine have been being for-profit, being accredited, offering detox, and using naltrexone.\u003csup\u003e\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e,\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e,\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e\u003c/sup\u003e However, some studies have mixed results on whether being for-profit and having accreditation are significantly associated with the adoption of buprenorphine.\u003csup\u003e\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e,\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e,\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e \u003cp\u003eAccreditation, given by a regulatory authority, is an important program and quality assessment tool for EBPs that supports consistency and reliability of services .\u003csup\u003e\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e,\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e\u003c/sup\u003e Accreditation, licensure, and credentialing can also help facilities obtain federal and state funding, such as using Medicaid and Medicare.\u003csup\u003e\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e\u003c/sup\u003e Privately owned facilities are more likely to be accredited, and this has been linked to having more resources and services. \u003csup\u003e\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e,\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e\u003c/sup\u003e In two different national studies using 2017 treatment data, accredited residential facilities were more likely to offer MOUD.\u003csup\u003e\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e,\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e\u003c/sup\u003e Accreditation, recognized as a bridging factor, helps connect internal and external contexts during the implementation and sustainment phases of EPIS, facilitating the delivery and continuity of MOUD.\u003csup\u003e\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e,\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e \u003cp\u003eThe outer context also significantly impacts MOUD availability, which is associated with program funding, ownership, and insurance.\u003csup\u003e\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e\u003c/sup\u003e In January 2014, the Medicaid expansion of the Patient Protection and Affordable Care Act of 2010 (ACA) was implemented to help increase access to SUDT.\u003csup\u003e\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e\u003c/sup\u003e States like California that incorporated Medicaid expansion saw an increase in buprenorphine prescriptions paid through Medicaid. California also implemented the Drug Medi-Cal Organized Delivery System (DMC-ODS), which intended to make substance use treatment, like MOUD, more accessible and evidence-based, while expanding Medicaid care.\u003csup\u003e\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e\u003c/sup\u003e Medicaid expansions and coverage of medications are found to increase the availability of MOUD.\u003csup\u003e\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e\u003c/sup\u003e Private insurance is the most common source of payment for MOUD, but public insurance also plays an important role, with Medicaid recipients being more likely to receive MOUD.\u003csup\u003e\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e,\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e \u003cp\u003eIn summary, the EPIS Framework highlights the importance of organizational factors (bridging factors) and external funding structures (outer context) in the implementation and sustainment of MOUD in SUDT facilities. This study hypothesizes that for-profit, accredited facilities and those accepting private insurance, government funding, and Medicaid will be more likely to offer MOUD. By understanding these implementation factors, the study aims to inform strategies that could improve the availability and utilization of MOUD, ultimately contributing to better treatment outcomes for individuals with OUD.\u003c/p\u003e"},{"header":"METHODS","content":"\u003cp\u003eThis study used data from the 2019 National Survey of Substance Abuse Treatment Services (N-SSATS), an annual survey of U.S. SUDT facilities that is nationally representative.\u003csup\u003e\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e\u003c/sup\u003e Data were collected between March and December 2019, with 15,961 of 17,808 eligible facilities responding, and 1,797 California facilities were included in this study. Facilities excluded were those that did not provide substance use treatment, such as halfway houses, solo practitioners, or jails. The survey\u0026rsquo;s item-response rate was about 99%.\u003csup\u003e30\u003c/sup\u003e\u003c/p\u003e \u003cp\u003eTo assess if facilities offered MOUD, a dichotomous variable was created, called MOUD sustainment, with yes being if they offer any of the following medications: Methadone, Naltrexone (oral), Naltrexone (extended-release, injectable), buprenorphine with naloxone, buprenorphine without naloxone, buprenorphine sub-dermal implant, buprenorphine (extended-release, injectable).\u003c/p\u003e \u003cp\u003eIndependent variables were based on the EPIS constructs of bridging factors and the outer context. Bridging variables consisted of the organization that operates the facility, a mutually exclusive categorical variable consisting of private for-profit organization; private non-profit organization; state government; local, county, or community government; tribal government; federal government. This variable was recoded bycombining all government-run entities, leading to facilities being categorized as private for-profit, private non-profit, or government-owned. Accreditation status was also a bridging factor variable. Outer context factors examined included funding, categorized by the types of payment accepted (cash, private health insurance, Medicaid, Medicare, state-financed insurance, federal military insurance, and IHS/Tribal/Urban funds) and whether the facility received government funding. Types of payment were not mutually exclusive.\u003c/p\u003e \u003cp\u003eMissing data were assessed, and chi-square analyses showed that missing data was not random, with significant differences in missing responses from 19 facilities, mostly private non-profits that did not offer MOUD. These facilities were excluded from the analysis. A sensitivity analysis confirmed no significant difference when they were included.\u003c/p\u003e \u003cp\u003eStatistical analyses were conducted in SPSS Version 28, with descriptive statistics, chi-square tests for differences in funding and accreditation by facility type, and multiple logistic regressions to determine predictors of offering MOUD.\u003csup\u003e\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e\u003c/sup\u003e All variables were tested for multicollinearity with variables having a correlation coefficient of 0.80 not being maintained.\u003csup\u003e\u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e\u003c/sup\u003e None of the variables were correlated over 0.80. For chi-square tests, post-hoc tests were conducted on significant results to see which facility was significant. This was done by looking at the adjusted residual and using the Bonferroni Correction method to adjust for Type 1 errors, with the alpha being set at .0167. For logistic regressions, an alpha level of p\u0026thinsp;\u0026lt;\u0026thinsp;.05 was deemed significant.\u003c/p\u003e"},{"header":"RESULTS","content":"\u003cp\u003eTable\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e \u003cb\u003ewill go here.\u003c/b\u003e\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eDescriptive Statistics of MOUD Offered\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"5\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePrivate for-profit org\u003c/p\u003e \u003cp\u003e777 (43.7%)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003ePrivate non-profit org\u003c/p\u003e \u003cp\u003e796 (44.8%)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eGovernment Owned\u003c/p\u003e \u003cp\u003e205 (11.5%)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/th\u003e \u003c/tr\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMedically Assisted Treatment Type\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003eN(%)\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMethadone\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e146 (18.8%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e48 (6.0%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e15 (7.2%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e209 (11.8%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBuprenorphine\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e392 (50.5%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e102 (12.8%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e32 (15.6%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e526 (29.6%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBuprenorphine with naloxone\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e502 (64.6%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e163 (20.5%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e52 (25.4%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e717 (40.3%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBuprenorphine Sub-dermal implant\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e90 (11.6%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e20 (2.5%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e2 (1.0%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e112\u003c/p\u003e \u003cp\u003e(6.3%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBuprenorphine (extended-release, injectable)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e196 (25.2%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e32 (4.0%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e10 (4.9%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e238 (13.4%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNaltrexone (oral)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e464 (59.7%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e125 (15.7%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e55 (26.8%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e644\u003c/p\u003e \u003cp\u003e(36.2%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNaltrexone (extended-release injectable)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e403 (51.9%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e124 (15.6%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e51 (24.9%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e578\u003c/p\u003e \u003cp\u003e(32.5%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMOUD Offered at Facility\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e585 (75.3%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e198 (24.9%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e65 (31.7%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e848\u003c/p\u003e \u003cp\u003e(47.7%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eTable\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e shows the different types of MOUD offered. The MOUD offered the most were Buprenorphine with naloxone, Naloxone (oral), and Naloxone (injectable). Overall, 47.7% of facilities were found to offer any sort of MOUD, with 75.3% of private for-profit facilities offering MOUD. When it came to ownership type, 24.9% of private non-profit facilities offered MOUD, and 31.7% of government-owned facilitiesoffered MOUD.\u003c/p\u003e \u003cp\u003eTable\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e \u003cb\u003ewill go here.\u003c/b\u003e\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eDescriptive Statistics of Independent Variables\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"4\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colspan=\"3\" nameend=\"c3\" namest=\"c1\"\u003e \u003cp\u003eBridging Factor Variables\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003en (%)\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"3\" nameend=\"c3\" namest=\"c1\"\u003e \u003cp\u003eOrganization that Operates the Facility\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003ePrivate For-Profit\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e777 (43.7%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003ePrivate Non-Profit\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e796 (44.8%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eGovernment Owned\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e205 (11.5%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"3\" nameend=\"c3\" namest=\"c1\"\u003e \u003cp\u003eFacility is licensed, certified, or accredited to provide substance use services\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e963 (54.2%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e813 (45.8%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"3\" nameend=\"c3\" namest=\"c1\"\u003e \u003cp\u003e\u003cb\u003eOuter Context Variables\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cb\u003en (%)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"3\" nameend=\"c3\" namest=\"c1\"\u003e \u003cp\u003eCash or self-payment\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1511 (85.0%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e267 (15.0%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"3\" nameend=\"c3\" namest=\"c1\"\u003e \u003cp\u003ePrivate health insurance\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1130 (63.6%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e648 (36.4%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"3\" nameend=\"c3\" namest=\"c1\"\u003e \u003cp\u003eMedicaid\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e685 (38.5%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1093 (61.5%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"3\" nameend=\"c3\" namest=\"c1\"\u003e \u003cp\u003eMedicare\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e362 (20.4%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1416 (79.6%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"3\" nameend=\"c3\" namest=\"c1\"\u003e \u003cp\u003eState-financed health insurance plan other than Medicaid\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e432 (24.3%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1346 (75.7%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"3\" nameend=\"c3\" namest=\"c1\"\u003e \u003cp\u003eFederal military insurance\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e391 (22.0%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1387 (78.0%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"3\" nameend=\"c3\" namest=\"c1\"\u003e \u003cp\u003eIHS/Tribal/Urban funds\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e291 (16.4%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1487 (83.6%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"3\" nameend=\"c3\" namest=\"c1\"\u003e \u003cp\u003eFacility receives funding from the government\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e782 (45.9%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e922 (53.7%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eA total of 1,778 facilitates from California were included in the 2019 N-SSATS data. The breakdown of the organization that operates the facility can be seen in Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e. When looking at ownership type, 43.7% of facilities were private for-profit organizations, 44.8% were private non-profit organizations, and 11.5% were government owned. More than half (54.2%) of facilities were accredited. The most accepted payment types were cash or self-pay (85.0%), and private insurance (63.6%). Only 38.5% of SUDT facilities accepted Medicaid, and all other insurances were accepted at 16%-25% of facilities. In total, 45.9% (N\u0026thinsp;=\u0026thinsp;782) of California facilities receive funding from the government to support their substance use treatment programs.\u003c/p\u003e \u003cp\u003eTable\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e \u003cb\u003ewill go here.\u003c/b\u003e\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab3\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eType of Funding Source Accepted by Type of Operating Organization\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"5\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAccepted Funding\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePrivate for-profit org\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003ePrivate non-profit org\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eGovernment\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003eChi-Square (p-value)\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFacility receives funding from the government\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e57 (7.5%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e542 (72.3%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e183 (92.4%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e830.58 (\u0026lt;\u0026thinsp;.001)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCash or self-payment\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e759 (97.7%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e623 (78.3%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e129 (62.9%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e204.49 (\u0026lt;\u0026thinsp;.001)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePrivate health insurance\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e713 (91.8%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e328 (41.2%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e89 (43.4%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e474.47 (\u0026lt;\u0026thinsp;.001)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMedicaid\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e128 (16.5%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e424 (53.3%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e133 (64.9%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e292.68 (\u0026lt;\u0026thinsp;.001)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMedicare\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e59 (7.6%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e220 (27.6%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e83 (40.5%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e155.33 (\u0026lt;\u0026thinsp;.001)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eState-financed health insurance plan other than Medicaid\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e123 (15.8%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e227 (28.5%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e82 (40.0%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e65.48 (\u0026lt;\u0026thinsp;.001)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFederal military insurance\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e263 (33.8%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e83 (10.4%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e45 (22.0%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e125.73 (\u0026lt;\u0026thinsp;.001)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eIHS/Tribal/Urban funds\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e171 (22.0%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e91 (11.4%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e29 (14.1%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e32.96 (\u0026lt;\u0026thinsp;.001)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFacility is licensed, certified, or accredited to provide substance use services\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e633 (81.6%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e286 (35.4%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e50 (24.0%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e424.71 (\u0026lt;\u0026thinsp;.001)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eTable\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e presents the percentage of facilities that accepted funding types and the chi-square results of the relationships between funding types and the organization that operates the facility. Receiving funding from the government was statistically significant in association with the organization that operates the facility (\u003cem\u003eX\u003c/em\u003e\u003csup\u003e\u003cem\u003e\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e\u003c/em\u003e\u003c/sup\u003e\u003csub\u003e(2, 1704)\u003c/sub\u003e\u0026thinsp;=\u0026thinsp;838.04, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;.001). Most facilities that are government-owned receive funding from the government (92.4%). Only 57 (7.5%) private for-profit facilities received government funding.\u003c/p\u003e \u003cp\u003eThere was a statistically significant difference in accepting cash or self-payment (\u003cem\u003eX\u003c/em\u003e\u003csup\u003e\u003cem\u003e\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e\u003c/em\u003e\u003c/sup\u003e\u003csub\u003e(2, 1778)\u003c/sub\u003e\u0026thinsp;=\u0026thinsp;204.49, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;.001). In terms of directionality, there seems to be an association between the operating organization and accepted funding, as a significantly higher percentage of private for-profit facilities (97.7%) accepted cash or self-payment, relative to private non-profit (78.3%), and government-owned facilities (62.9%). There was also a statistically significant difference in accepting private health insurance (\u003cem\u003eX\u003c/em\u003e\u003csup\u003e\u003cem\u003e\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e\u003c/em\u003e\u003c/sup\u003e\u003csub\u003e(2, 1778)\u003c/sub\u003e\u0026thinsp;=\u0026thinsp;474.47, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;.001), military insurance (\u003cem\u003eX\u003c/em\u003e\u003csup\u003e\u003cem\u003e\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e\u003c/em\u003e\u003c/sup\u003e\u003csub\u003e(2, 1778)\u003c/sub\u003e\u0026thinsp;=\u0026thinsp;125.73, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;.001) and tribal insurance (\u003cem\u003eX\u003c/em\u003e\u003csup\u003e\u003cem\u003e\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e\u003c/em\u003e\u003c/sup\u003e\u003csub\u003e(2, 1778)\u003c/sub\u003e\u0026thinsp;=\u0026thinsp;32.96, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;.001), with private for-profit facilities having higher percentages of accepting them compared to private non-profit and government-owned facilities. Additionally, there was a statistically significant difference in being accredited and facility type (\u003cem\u003eX\u003c/em\u003e\u003csup\u003e\u003cem\u003e\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e\u003c/em\u003e\u003c/sup\u003e\u003csub\u003e(2, 1776)\u003c/sub\u003e\u0026thinsp;=\u0026thinsp;427.02, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;.001), with a higher percentage of for-profit facilities (81.7%) being accredited compared to 35.4% of private non-profit and 23.4% government-owned facilities.\u003c/p\u003e \u003cp\u003eThere was a statistically significant association in accepting Medicaid (\u003cem\u003eX\u003c/em\u003e\u003csup\u003e\u003cem\u003e\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e\u003c/em\u003e\u003c/sup\u003e\u003csub\u003e(2, 1778)\u003c/sub\u003e\u0026thinsp;=\u0026thinsp;292.68, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;.001), Medicare (\u003cem\u003eX\u003c/em\u003e\u003csup\u003e\u003cem\u003e\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e\u003c/em\u003e\u003c/sup\u003e\u003csub\u003e(2, 1778)\u003c/sub\u003e 155.33, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;.001), and other state-financed insurance (\u003cem\u003eX\u003c/em\u003e\u003csup\u003e\u003cem\u003e\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e\u003c/em\u003e\u003c/sup\u003e\u003csub\u003e(2, 1778)\u003c/sub\u003e 65.48, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;.001) and operating organization type. A higher percentage of government-owned facilities (64.9%) accepted Medicaid, relative to private for-profit facilities (16.5%) and private non-profit facilities (53.3%). Government-owned facilities (40.5%) also accepted Medicare at a higher rate compared to private for-profit facilities (7.6%) and private non-profit facilities (28.5%). Lastly, government-owned facilities (40.0%) accepted other state-financed insurances at a higher rate than private for-profit facilities (15.8%) and private non-profit facilities (28.5%).\u003c/p\u003e \u003cp\u003eTable\u0026nbsp;\u003cspan refid=\"Tab4\" class=\"InternalRef\"\u003e4\u003c/span\u003e \u003cb\u003ewill go here.\u003c/b\u003e\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab4\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 4\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eType of Funding Source Accepted by Accreditation\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"4\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAccepted Funding\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNot Accredited\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eAccredited\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eChi-Square (p-value)\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFacility receives funding from the government\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e517 (66.1%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e265 (33.9%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e254.39 (\u0026lt;\u0026thinsp;.001)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCash or self-payment\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e630 (77.5%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e879 (91.3%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e65.59 (\u0026lt;\u0026thinsp;.001)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePrivate health insurance\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e288 (35.4%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e841(87.3%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e512.88 (\u0026lt;\u0026thinsp;.001)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMedicaid\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e378 (46.5%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e307 (31.9%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e39.74 (\u0026lt;\u0026thinsp;.001)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMedicare\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e226 (27.8%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e136 (14.1%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e50.81 (\u0026lt;\u0026thinsp;.001)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eState-financed health insurance plan other than Medicaid\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e219 (26.9%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e213 (22.1%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e5.56 (.018)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFederal military insurance\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e81 (10.0%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e310 (32.2%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e126.86 (\u0026lt;\u0026thinsp;.001)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eIHS/Tribal/Urban funds\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e97 (11.9%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e194 (20.1%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e21.71 (\u0026lt;\u0026thinsp;.001)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eTable\u0026nbsp;\u003cspan refid=\"Tab4\" class=\"InternalRef\"\u003e4\u003c/span\u003e presents the percentages of organizations having accreditation or not and what funding they receive, along with the chi-square results of the relationships. Facilities that were accredited were more likely to accept cash or self-payment (\u003cem\u003eX\u003c/em\u003e\u003csup\u003e\u003cem\u003e\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e\u003c/em\u003e\u003c/sup\u003e\u003csub\u003e(2, 1776)\u003c/sub\u003e 65.59, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;.001), private health insurance (\u003cem\u003eX\u003c/em\u003e\u003csup\u003e\u003cem\u003e\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e\u003c/em\u003e\u003c/sup\u003e\u003csub\u003e(2, 1776)\u003c/sub\u003e 512.88, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;.001), federal military insurance (\u003cem\u003eX\u003c/em\u003e\u003csup\u003e\u003cem\u003e\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e\u003c/em\u003e\u003c/sup\u003e\u003csub\u003e(2, 1776)\u003c/sub\u003e 126.86, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;.001), and IHS/Tribal/Urban funds (\u003cem\u003eX\u003c/em\u003e\u003csup\u003e\u003cem\u003e\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e\u003c/em\u003e\u003c/sup\u003e\u003csub\u003e(2, 1776)\u003c/sub\u003e 21.71, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;.001). Facilities that were not accredited were more likely to receive government funding (\u003cem\u003eX\u003c/em\u003e\u003csup\u003e\u003cem\u003e\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e\u003c/em\u003e\u003c/sup\u003e\u003csub\u003e(2, 1702)\u003c/sub\u003e 254.39, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;.001), Medicaid (\u003cem\u003eX\u003c/em\u003e\u003csup\u003e\u003cem\u003e\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e\u003c/em\u003e\u003c/sup\u003e\u003csub\u003e(2, 1776)\u003c/sub\u003e 39.74, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;.001), and Medicare (\u003cem\u003eX\u003c/em\u003e\u003csup\u003e\u003cem\u003e\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e\u003c/em\u003e\u003c/sup\u003e\u003csub\u003e(2, 1776)\u003c/sub\u003e 50.81, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;.001).\u003c/p\u003e \u003cp\u003eTable\u0026nbsp;\u003cspan refid=\"Tab5\" class=\"InternalRef\"\u003e5\u003c/span\u003e \u003cb\u003ewill go here.\u003c/b\u003e\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab5\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 5\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eUnadjusted and Adjusted Multiple Logistic Regressions of SUD Facility Characteristics Associated offering MAUD and MOUD\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"5\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colspan=\"4\" nameend=\"c5\" namest=\"c2\"\u003e \u003cp\u003eMOUD Offered\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e \u003cp\u003eUnadjusted Odds Ratio\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colspan=\"2\" nameend=\"c5\" namest=\"c4\"\u003e \u003cp\u003eAdjusted Odds Ratio\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eOdds Ratio\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eConfidence Interval\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eOdds Ratio\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eConfidence Interval\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eOrganization that operates the facility\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePrivate for-profit org\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e(Ref)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e(Ref)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePrivate non-profit org\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0.11**\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.09, 0.14\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.67\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.40, 1.12\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eGovernment Owned\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0.15**\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.11, 0.21\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.33**\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.23, 0.47\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eFacility is accredited to provide substance abuse services\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e11.60**\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e9.23, 14.53\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e5.23**\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e3.97, 6.90\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eAccepted Payment Types\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCash or self-payment\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3.05**\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2.28, 4.10\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.84\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.56, 1.27\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePrivate health insurance\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e11.63**\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e9.05, 14.93\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e2.96**\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e2.10, 4.16\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMedicaid\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0.49**\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.40, 0.59\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1.07\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.79, 1.45\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMedicare\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0.61**\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.48, 0.78\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1.17\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.82, 1.65\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eState-financed health insurance\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0.91\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e.073, 1.13\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1.02\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.75, 1.41\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFederal military insurance\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e4.00**\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e3.12, 5.12\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1.28\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.93, 1.76\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eIHS/Tribal/Urban funds\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2.55**\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1.96, 3.32\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1.49*\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e1.05, 2.12\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eFacility receives funding from the government\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0.19**\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.16, 0.24\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.69*\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.48, 0.98\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"5\" nameend=\"c5\" namest=\"c1\"\u003e \u003cp\u003e*Significant at \u0026lt;\u0026thinsp;.05\u003c/p\u003e \u003cp\u003e**Significant at \u0026lt;\u0026thinsp;.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eTable\u0026nbsp;\u003cspan refid=\"Tab5\" class=\"InternalRef\"\u003e5\u003c/span\u003e shows the unadjusted and adjusted results of logistic regressions of all independent variables and if they are associated with whether the facilities offer MOUD. In the adjusted analysis, government-owned facilities (AOR: 0.33; 95% CI: 0.23, 0.47) had lower odds of offering MOUD when compared to private for-profit organizations, meaning that private for-profit facilities are about three times more likely to offer MOUD than those that are government-owned. Private non-profit organizations had lower odds of offering MOUD (OR: 0.11; 95% CI: 0.09, 0.14) compared to private for-profit organizations in the bivariate logistic regression, but this was no longer significant in the adjusted model (AOR: 0.67; 95% CI: 0.40, 1.12). Facilities that had accreditations were over 5 times more likely to offer MOUD than those that were not (AOR: 5.23; 95% CI: 3.97, 6.90)\u003c/p\u003e \u003cp\u003eFacilities that accepted private health insurance were almost 3 times more likely to offer MOUD (AOR: 2.96; 95% CI: 2.10, 4.16) and facilities that accept IHS/Tribal/Urban funds were almost 1.5 times more likely to offer MOUD (AOR: 1.49; 95% CI: 1.05, 2.12). Facilities receiving funding from the government to support their substance use program showed lower odds of offering MOUD (AOR: 0.69; 95% CI: 0.48, 0.98), or facilities that don\u0026rsquo;t receive funding from the government are 1.45 times more likely to offer MOUD. In the bivariate logistic regression, accepting Medicaid was associated with lower odds of offering MOUD (OR: 0.49; 95% CI: 0.40, 0.59), but this relationship was no longer significant in the adjusted model (AOR: 1.07; 95% CI: 0.79, 1.45).\u003c/p\u003e"},{"header":"DISCUSSION","content":"\u003cp\u003eGuided by the EPIS Framework, this study examined the implementation factors related to the sustainment of MOUD in SUDT facilities in California. In 2019, only 47.4% of Californian facilities offered any type of MOUD. Key findings identified bridging factors, such as accreditation and the organization that operates a facility, that were associated with a significantly higher likelihood of offering MOUD. Having accreditation was associated with being five times more likely to offer MOUD. When compared to private for-profit organizations, government-owned organizations are less likely to offer MOUD. When it came to the outer context element of funding, facilities that accepted private health insurance and IHS/Tribal/Urban funds were more likely to offer MOUD, while facilities receiving grant money were less likely to offer MOUD.\u003c/p\u003e \u003cp\u003eTo our knowledge, this is one of the first studies to apply the EPIS Framework to assess MOUD implementation and sustainment in SUDT facilities in California, with a specific focus on bridging factors, which are often left out in implementation studies.\u003csup\u003e\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e\u003c/sup\u003e Our findings suggest that bridging factors, including the organization type and accreditation, can connect facilities from the outer context of funding, such as how the organization that operates the facility or accreditation is connected to funding sources and how these factors help the implementation and sustainment of EBPs.\u003csup\u003e\u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e\u003c/sup\u003e For example, private for-profit and accredited facilities were more likely to accept private and tribal insurance, which were associated with higher odds of offering MOUD. Policymakers could utilize these findings to promote accreditation accessibility and encourage facilities to accept different insurance types to improve MOUD delivery and sustainment.\u003c/p\u003e \u003cp\u003eAccredited facilities were over five times more likely to offer MOUD than those that were not, which aligns with past research.\u003csup\u003e\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e,\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e,\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e,\u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e,\u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e\u003c/sup\u003e Facilities that are accredited have been found to sustain the use of MOUDs longer than those without accreditation.\u003csup\u003e\u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e\u003c/sup\u003e Implementation of MOUD may be higher in accredited facilities as they are part of a social network of other SUDT facilities that creates pressure and accountability to use up-to-date EBPs.\u003csup\u003e\u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e\u003c/sup\u003e However, accreditation is costly and may not be viable for public organizations that operate within a smaller budget.\u003csup\u003e\u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e36\u003c/span\u003e\u003c/sup\u003e Future policies could offer financial incentives to make accreditation more accessible to government-owned facilities. However, it\u0026rsquo;s important to note that accreditation does not necessarily correlate with better patient outcomes, as some accredited facilities may have lower patient experience scores.\u003csup\u003e\u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e36\u003c/span\u003e\u003c/sup\u003e SUDT facilities with accreditation have been found to offer admission to potential patients without doing a complete clinical evaluation.\u003csup\u003e\u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e37\u003c/span\u003e\u003c/sup\u003e If accreditation becomes the standard for SUDT, further quality control of what accrediting bodies are assessing will need to be more transparent to ensure that MOUD is being offered in facilities and actually being utilized to sustain the use of MOUD.\u003c/p\u003e \u003cp\u003eAs this study found, SUDT programs that are privately owned are more likely to hold accreditation, both of which are related to a higher quality of care and can further disadvantage those who do not have the means to access treatment.\u003csup\u003e \u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e \u003c/sup\u003e In recent years, there has been an increase in private for-profit facilities and a decrease in publicly owned ones.\u003csup\u003e \u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e \u003c/sup\u003e For-profit programs can be costly, with some asking for over \u003cspan\u003e$\u003c/span\u003e17,000 to be admitted into treatment, which is higher than the average person with an opioid use disorder can afford.\u003csup\u003e \u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e37\u003c/span\u003e \u003c/sup\u003e Furthermore, private for-profit and accredited facilities are more likely to offer MOUD. This could be because for-profit facilities have more financial means to be innovative and adopt new practices.\u003csup\u003e \u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e \u003c/sup\u003e To keep up with treatment costs, for-profit agencies might have to keep up with EBPs and treatment options to entice patients to come to services.\u003csup\u003e \u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e \u003c/sup\u003e Although these facilities are more likely to offer MOUD, research has shown that only a small percentage of patients in such facilities receive the treatment.\u003csup\u003e \u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e38\u003c/span\u003e \u003c/sup\u003e Therefore, there may be a discrepancy between facilities offering MOUD and patients receiving it. Future studies should explore the disconnect between facilities offering MOUD and patients\u0026rsquo; ability to access it due to financial constraints, attitudes toward MOUD, or insurance type.\u003c/p\u003e \u003cp\u003eCalifornia SUDT facilities primarily consist of private for-profit and non-profit organizations, with over 60 percent accepting private insurance and less than 40 percent accepting Medicaid. Facilities taking private insurance were more likely to offer MOUD. The number of facilities accepting Medicaid is low (38.5%), considering California has the most extensive Medicaid program in the United States.\u003csup\u003e\u003cspan citationid=\"CR39\" class=\"CitationRef\"\u003e39\u003c/span\u003e\u003c/sup\u003e Contradictory to our findings, Medicaid expansions, and coverage of medications have been found to increase the availability of MOUD.\u003csup\u003e\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e\u003c/sup\u003e With California participating in these Medicaid expansions and having the largest Medicaid program, we expected to see Medicaid as an implementation factor related to offering MOUD, which was not the case. In past studies, insurance was the most crucial element in being on MOUD, with people on public insurance being more likely to be on MOUD than those with private insurance.\u003csup\u003e\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e\u003c/sup\u003e This could be due to Medicaid programs often requiring prior authorization for medications, which is associated with lower odds of offering MOUD.\u003csup\u003e\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e\u003c/sup\u003e It could also be that more for-profit facilities offer MOUD, but that MOUD is more accessible to those with public insurance. This disconnect could not be assessed with this data as we were unable to see the percentage of patients who received MOUD. If Medicaid is an enabling factor in being on MOUD, then further policy changes could focus on encouraging SUDT facilities to take Medicaid, whether by increasing reimbursement rates or offering other incentives to accept this insurance type.\u003c/p\u003e \u003cp\u003eLastly, government funding is a factor that facilitates the implementation of certain EBPs.\u003csup\u003e\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e\u003c/sup\u003e While government-owned facilities were more likely to receive government funding, they were less likely to offer MOUD. Most government-owned facilities received government funding. If the organization that operates a facility is a bridging factor between the outer and inner contexts, then this suggests that funding is related to the type of facility and can affect the type of EBPs that are being offered. Future policies could focus on requiring government-owned facilities to implement more EBPs and to obtain accreditation that ensures these practices are followed. Changes in government funding could provide funding to facilities if they use MOUD, which may help increase the availability of MOUD in SUDT facilities.\u003c/p\u003e \u003cp\u003eThis study had limitations, including the exclusion of solo practitioners and primary care physicians who may also provide MOUD. This means other entities may provide SUDT that do not fall under the SUDT facilities umbrella of the study, and more options may be available for people who want MOUD. Additionally, the N-SSATS dataset did not capture information about the number of physicians who could prescribe MOUD at the SUDT facilities, which could impact the delivery of these treatments. Future studies should address these gaps to better understand the barriers to MOUD access and improve its delivery across different settings.\u003c/p\u003e"},{"header":"CONCLUSION","content":"\u003cp\u003eTo our knowledge, this is the first study to use the EPIS framework to understand implementation factors that are associated with the sustainment of MOUD. To better meet the needs of people with substance use disorders, implementation efforts must be concentrated on evidence-based practices, especially medication-assisted therapies. This study's findings suggest that policy interventions focused on accreditation, funding models, and insurance acceptance could be key strategies to improve the delivery and sustainment of MOUD in SUDT facilities. Efforts to make accreditation more accessible and encourage facilities to accept diverse forms of insurance, and increasing reimbursement rates for Medicaid, may help increase MOUD access, providing a more effective means of combating the opioid epidemic. Future studies could concentrate on how policies like the DMC-ODS and Medicaid expansion are increasing the accessibility of MOUD and clarifying if Medicaid is an enabling factor of being on MOUD. Lastly, future policy changes can focus on the push for utilizing MOUD as an EBP for treating opioid use disorders and encouraging their use in SUDT facilities.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cp\u003eMedication for opioid use disorders (MOUD)\u003c/p\u003e\n\u003cp\u003eSubstance use disorder treatment (SUDT)\u003c/p\u003e\n\u003cp\u003eNational Survey of Substance Abuse Treatment Services (N-SSATS)\u003c/p\u003e\n\u003cp\u003eFood and Drug Administration (FDA)\u003c/p\u003e\n\u003cp\u003eAmerican Society of Addiction Medicine (ASAM)\u003c/p\u003e\n\u003cp\u003eWorld Health Organization (WHO)\u003c/p\u003e\n\u003cp\u003eOpioid use disorder (OUD)\u003c/p\u003e\n\u003cp\u003eExploration, Preparation, Implementation, Sustainability (EPIS) Framework\u003c/p\u003e\n\u003cp\u003eEvidence based practices (EBPs),\u003c/p\u003e\n\u003cp\u003eAffordable Care Act of 2010 (ACA)\u003c/p\u003e\n\u003cp\u003eDrug Medi-Cal Organized Delivery System (DMC-ODS),\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate:\u0026nbsp;\u003c/strong\u003eThis research was IRB exempt due to being secondary data that was publicly available.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication:\u003c/strong\u003e Not applicable\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data and materials:\u0026nbsp;\u003c/strong\u003eThe data that support the findings of this study are available from SAMHSA repository, and available at:\u0026nbsp;https://www.samhsa.gov/data/report/national-survey-substance-abuse-treatment-services-n-ssats-2019-data-substance-abuse.\u003csup\u003e30\u003c/sup\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests:\u0026nbsp;\u003c/strong\u003eThe authors declare that they have no competing interests\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding:\u0026nbsp;\u003c/strong\u003eNo funding was used for this research.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors\u0026apos; contributions:\u0026nbsp;\u003c/strong\u003eMN and LRS analyzed and interpreted the data. MN was a major contributor in writing the manuscript. AW and LAU provided feedback on the manuscript. All authors read and approved the final manuscript.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgements\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eMJN would like to acknowledge her dissertation committee from the Joint Doctoral Program in Interdisciplinary Research and Substance Use and San Diego State University and University of California San Diego who helped her through this process. This research had no funding support.\u0026nbsp;\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eAmerican Medical Association Advocacy Resource Center. Issue Brief: Nation\u0026rsquo;s drug-related overdose and death epidemic continues to worsen. American Medical Association. 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Utilization and outcomes of detoxification and maintenance treatment for opioid dependence in publicly-funded facilities in California, USA: 1991\u0026ndash;2012. Drug Alcohol Depend. 2014;143:149\u0026ndash;57.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eNorris L. California and the ACA\u0026rsquo;s Medicaid expansion. Healthinsurance.org. January 26, 2022. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://www.healthinsurance.org/medicaid/california/\u003c/span\u003e\u003cspan address=\"https://www.healthinsurance.org/medicaid/california/\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e. Accessed August 29, 2022.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"substance-abuse-treatment-prevention-and-policy","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"satp","sideBox":"Learn more about [Substance Abuse Treatment, Prevention, and Policy](http://substanceabusepolicy.biomedcentral.com)","snPcode":"13011","submissionUrl":"https://submission.nature.com/new-submission/13011/3","title":"Substance Abuse Treatment, Prevention, and Policy","twitterHandle":"@BioMedCentral","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"BMC/SO AJ","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Medication for Opioid Use Disorders, Implementation, Buprenorphine, Methadone, Treatment","lastPublishedDoi":"10.21203/rs.3.rs-6307033/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-6307033/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e \u003cp\u003eThe use of medication for opioid use disorders (MOUD) are not keeping up with the rise of the opioid epidemic. There is mixed research on how MOUD is utilized in different treatment settings for substance use disorders. This study explored factors influencing the implementation of medication for opioid use disorders (MOUD) in substance use disorder treatment (SUDT) facilities in California.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e \u003cp\u003eSecondary analyses of the 2019 National Survey of Substance Abuse Treatment Services (N-SSATS) data were conducted, focusing on facility type, funding, and accreditation. Chi-square analyses and multiple logistic regressions were used to examine associations with offering MOUD.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e \u003cp\u003eA total of 1,778 California facilities were surveyed, with 47.7% offering MOUD. Significant differences in facility type and funding sources were observed. Private for-profit facilities were more likely to accept cash/self-payment, federal military insurance, and IHS/tribal/urban funds (all p\u0026thinsp;\u0026lt;\u0026thinsp;.001), while government-owned facilities were more likely to accept government funding, Medicaid, Medicare, and state-financed insurance (all p\u0026thinsp;\u0026lt;\u0026thinsp;.001). Accreditation was associated with accepting cash/self-payment, federal military insurance, and IHS/tribal/urban funds (all p\u0026thinsp;\u0026lt;\u0026thinsp;.001) and was more common in private for-profit facilities (X\u003csup\u003e\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e\u003c/sup\u003e(2, 1776)\u0026thinsp;=\u0026thinsp;427.02, p\u0026thinsp;\u0026lt;\u0026thinsp;.001). Logistic regression revealed that government-owned facilities had lower odds of offering MOUD (AOR: 0.33; 95% CI: 0.23, 0.47), while accredited facilities (AOR: 5.23; 95% CI: 3.97, 6.90), those accepting private insurance (AOR: 2.96; 95% CI: 2.10, 4.16), and IHS/Tribal/Urban funds (AOR: 1.49; 95% CI: 1.05, 2.12) had higher odds. Government funding was associated with lower odds (AOR: 0.69; 95% CI: 0.48, 0.98).\u003c/p\u003e\u003ch2\u003eConclusions\u003c/h2\u003e \u003cp\u003eMOUD are underutilized in Californian substance use facilities. Accreditation, funding, and facility type significantly affect MOUD availability. Future policies should focus on increasing accreditation and aligning government funding and insurance with MOUD delivery.\u003c/p\u003e","manuscriptTitle":"California Substance Use Disorder Treatment Facility Characteristics Associated with Offering Medications for Opioid Use Disorder","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-04-29 14:11:32","doi":"10.21203/rs.3.rs-6307033/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2026-04-05T03:32:41+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-12-19T22:38:58+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"32231840787212188029402383410653617152","date":"2025-10-27T16:57:28+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"131694095179931403922905891566352710672","date":"2025-10-27T01:05:37+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"213327276176296299358651656098219685558","date":"2025-04-29T16:05:58+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2025-04-27T22:31:19+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2025-03-28T04:07:19+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2025-03-28T04:04:26+00:00","index":"","fulltext":""},{"type":"submitted","content":"Substance Abuse Treatment, Prevention, and Policy","date":"2025-03-25T22:37:52+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"substance-abuse-treatment-prevention-and-policy","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"satp","sideBox":"Learn more about [Substance Abuse Treatment, Prevention, and Policy](http://substanceabusepolicy.biomedcentral.com)","snPcode":"13011","submissionUrl":"https://submission.nature.com/new-submission/13011/3","title":"Substance Abuse Treatment, Prevention, and Policy","twitterHandle":"@BioMedCentral","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"BMC/SO AJ","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"e6304927-1b48-4796-bf19-fd3f9137395e","owner":[],"postedDate":"April 29th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"in-revision","subjectAreas":[],"tags":[],"updatedAt":"2026-04-05T03:38:33+00:00","versionOfRecord":[],"versionCreatedAt":"2025-04-29 14:11:32","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-6307033","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-6307033","identity":"rs-6307033","version":["v1"]},"buildId":"XKTyCvWXoU3ODBz1xrDgd","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}