Linked Child Welfare and Medicaid Data in Kentucky and Florida Highlights Racial Disparities in Access to Care.

Parents with serious mental health (MH) and substance use disorders (SUD) can face profound challenges caring for their children. MH/SUD treatment can improve outcomes for both parents and their children. This study evaluated whether parents with Medicaid with MH/SUD conditions whose children had child protective services (CPS) involvement were receiving MH/SUD treatment and whether receipt differed by race. We analyzed the 2020 Child and Caregiver Outcomes Using Linked Data (CCOULD) which contains Medicaid and child welfare records from Kentucky and Florida on 58,551 CPS-involved caregivers. Among caregivers with an MH diagnosis, White individuals were more likely than Black individuals to have received counseling (42% vs. 20%) or an MH medication (69% vs. 52%). Among caregivers with an SUD, White individuals were more likely than Black individuals to have received counseling (43% vs. 20%) or an SUD medication (43% vs. 11%). More effort is needed to connect parents with CPS involvement to MH/SUD treatment, particularly Black parents.

Association of Arizona's Implementation of a Behavioral Health Crisis Response System With Suicide Hospitalizations.

OBJECTIVE: In July 2022, the 988 Suicide and Crisis Lifeline went live. The Lifeline is part of larger federal and state efforts to build comprehensive behavioral health crisis response systems that include mobile crisis units and crisis diversion and stabilization centers. Comprehensive response systems are anticipated to reduce hospitalizations for suicide and other behavioral health crises; however, research testing this assumption has been limited. The authors used Arizona-a state known for its comprehensive crisis system-to determine the association between state implementation of a comprehensive behavioral health crisis response system and suicide-related hospitalizations. METHODS: A comparative interrupted time-series (CITS) design was used to compare changes in suicide-related hospitalizations after the 2015 implementation of Arizona's crisis response system (N=215,063). Data were from the 2010-2019 Healthcare Cost and Utilization Project (HCUP) State Inpatient Databases (SID). Nevada (N=84,091 hospitalizations) was used as a comparison state because it is a western state that had not yet implemented a comprehensive crisis system and had available HCUP SID data. The CITS model included controls for time-varying differences in state demographic composition. RESULTS: From 2010 to 2014 to 2019, annual suicide-related hospitalizations in Arizona increased from 122.0 to 324.2 to 584.5, respectively, per 100,000 people, and in Nevada, hospitalizations increased from 94.7 to 263.2 to 595.5, respectively, per 100,000 people. Arizona's crisis response system was associated with a significant relative decrease in the quarterly trend of 2.57 suicide-related hospitalizations per 100,000 people (p=0.033). CONCLUSIONS: More research is needed to understand how the implementation of a comprehensive crisis response system may affect suicide-related hospitalizations.

The cost of opioid use disorder-related conditions in Medicare.

BACKGROUND: Medicare coverage excludes some levels of substance use disorder (SUD) care, such as intensive outpatient and residential treatment. Expanding access to SUD treatment could increase Medicare spending. However, these costs could be offset if SUD treatment resulted in cost savings from reducing SUD-related medical events and SUD-related medical comorbidities. METHODS: This study estimated cost savings from expanding access to SUD treatment for persons with opioid use disorders (OUD) using three methods. First, we compared total Medicare fee-for-service spending on individuals with OUD and no treatment with OUD medications (MOUD) to Medicare spending on individuals without OUD after matching on age/sex/Medicare-Medicaid eligibility status. Second, we compared Medicare spending on individuals with OUD who received MOUD to spending individuals with OUD who did not receive MOUD. Third, we determined OUD-attributable Medicare spending for comorbid physical and mental conditions with a strong association with OUD. RESULTS: Beneficiaries with OUD but no MOUD totaled $15.8 billion more than beneficiaries without OUD. Beneficiaries with OUD but no MOUD totaled $12.1 billion more than individuals with OUD and MOUD. Lastly, Medicare spending on OUD-attributable comorbidities was $4.7 billion if all medical and mental health comorbidities were included and $3.0 billion with only medical comorbidities. The totals could be 1.7 times higher if Medicare Advantage enrollees were included. CONCLUSION: Expanding Medicare coverage of appropriate levels of care could improve access to effective treatment and reduce the costs associated with untreated OUD. This will likely result in substantial Medicare cost savings.

Substance Use Disorders Among Medicare Beneficiaries: Prevalence, Mental and Physical Comorbidities, and Treatment Barriers.

INTRODUCTION: This study aimed to determine the prevalence of treated and untreated substance use disorders among Medicare beneficiaries, the characteristics of Medicare beneficiaries with substance use disorders, and reasons for their unmet needs. METHODS: This study used data from the National Survey of Drug Use and Health, 2015-2019. Substance use disorder was defined based on DSM-IV dependence or abuse criteria. Descriptive analyses were conducted in 2021, including testing for differences in unadjusted means. RESULTS: Approximately 1.7 million Medicare beneficiaries were estimated to have past-year substance use disorder (8% of Medicare beneficiaries aged <65 years and 2% aged ≥65 years). Overall, 77% had an alcohol use condition, 16% had a prescription drug use condition, and 10% had a marijuana use condition. Of those who had past-year substance use disorder, 11% received treatment for their condition. Common reasons for not receiving treatment were lack of motivation (41%), financial barriers (33%), concern about what others might think (24%), logistical barriers such as lack of transportation (21%), and uncertainty about treatment efficacy (13%). Medicare beneficiaries with substance use disorders were more than twice as likely to have past-year serious psychological distress as those without substance use disorders (44% vs 21%, p<0.001 for those aged <65 years; 14% vs 4%, p<0.001 for those aged ≥65 years). Percentages of past-year suicidal ideation were also much higher among Medicare beneficiaries with substance use disorders than without (24% vs 6%, p<0.001 for those aged <65 years; 7% vs 2%, p=0.006 for those aged ≥65 years). CONCLUSIONS: Few Medicare beneficiaries who need substance use disorder treatment receive it. Reducing Medicare coverage gaps and stigma may help meet this need.

The association of Medicare Part D prior authorization for buprenorphine-naloxone with adherence to opioid use disorder treatment guidelines in the United States.

AIMS: To assess differences in the quality of opioid use disorder (OUD) treatment received by Medicare beneficiaries enrolled in health plans that used prior authorization (PA) for buprenorphine-naloxone compared with those enrolled in plans that did not use PA. DESIGN, SETTING AND PARTICIPANTS: Cross-sectional observational study, United States. Continuously enrolled beneficiaries (71 294) with an OUD who filled at least one prescription for buprenorphine-naloxone between March 2012 and July 2017. MEASUREMENTS: Percentage of patients tested for hepatis B, hepatis C, HIV and liver functioning; percentage of patients with urine drug screens and number of urine drug screens; continuous use of buprenorphine-naloxone for at least 180 days; co-use of benzodiazepines; number of outpatient visits with and without an OUD diagnosis. FINDINGS: PA was significantly associated with a lower likelihood of testing for hepatitis B [-3.5, 95% confidence interval (CI) = -4.4, -2.7] and C (-5.9, 95% CI = -6.9, -4.9), but the findings were inconclusive as to whether or not there was a difference in HIV (-1.1, 95% CI = -2.5, 0.4) or liver function testing (1.3, 95% CI = -0.1, 2.7). PA was associated with a lower likelihood of urine drug screening (-25.5, 95% CI = -26.8, -24.1) and with fewer drug screens (-2.5, 95% CI = -3.0, -2.1). Findings were inconclusive as to whether or not there was a difference in continuous use of buprenorphine-naloxone (0.3, 95% CI = -1.2, 1.8). PA was associated with fewer outpatient visits (-2.1, 95% CI = -3.0, -1.2) and fewer outpatient visits with an OUD diagnosis (-1.7, 95% CI = -2.1, -1.3). PA was associated with a lower likelihood of filling benzodiazepine prescriptions before and after buprenorphine-naloxone induction (-28.9, 95% CI = -29.6, -28.3) but a greater likelihood of only using benzodiazepines after buprenorphine-naloxone induction (10.6, 95% CI = 9.3, 11.8). CONCLUSIONS: US Medicare patients subject to prior authorization for buprenorphine-naloxone are not more likely to receive high-quality treatment for opioid use disorder than patients not subject to prior authorization.

Assessing Assessments: Substance use disorder treatment providers' perceptions of intake assessments.

Background: Assessments to determine patients' treatment needs and preferences when they begin substance use disorder (SUD) treatment are essential. The objectives of this paper are to identify the perspectives of providers who conduct assessments on (1) assessments' utility in determining the level of care where patients will receive treatment, (2) strategies to engage patients in treatment during assessments, and (3) assessment strengths and shortcomings. Methods: Semi-structured interviews were conducted with 30 California treatment providers who routinely perform SUD assessments for Medicaid beneficiaries. Interviews asked about the utility of assessment tools in determining appropriate levels of care, patient engagement during assessments, and strengths and shortcomings of intake assessment processes. Interviews were audio-recorded, transcribed, and analyzed by multiple researchers using template analysis. Results: Providers reported that assessments linked to level-of-care decision rules sometimes generate recommendations inconsistent with their clinical judgment, and that the timing of assessments can influence the quality of the information collected. Providers described engagement strategies that help patients feel more comfortable during assessments and that encourage more thoughtful and accurate responses. Providers valued assessments that helped ensure comprehensive collection of patient information, that allowed flexibility to probe for additional information and context, and that facilitated treatment planning. Providers did not like assessments that were long and repetitive or those that did not collect detailed information about patients' mental health and recovery environments. Conclusions: Assessments can be improved if providers conduct them in a manner that makes patients feel comfortable while building trust and rapport. Ensuring that assessments are not long or repetitive and giving comprehensive assessments once patients have developed trusting relationships with treatment programs can improve assessment processes. Further research is needed to optimize SUD assessments.

What's in an "ASAM-based Assessment?" Variations in Assessment and Level of Care Determination in Systems Required to Use ASAM Patient Placement Criteria.

OBJECTIVES: When clients begin substance use disorder (SUD) treatment, it is critical to ensure that they receive treatment that matches their needs and preferences. A growing number of payors are requiring the use of multidimensional assessments such as assessments based on the American Society of Addiction Medicine (ASAM) criteria, which describe 6 dimensions that should be used to inform decisions about patient placement. However, ASAM guidance does not list specific questions to ask or instruments to use to elicit this information. This paper evaluates differences among the assessment tools being used by SUD service systems that are required to use ASAM-based assessments to make patient placement decisions. METHODS: We analyzed 29 different ASAM-based assessments being used by California counties to make patient placement decisions using conventional and summative content analysis techniques. RESULTS: All assessments were organized by the 6 ASAM dimensions. However, some of them only ask 1 or 2 questions per dimension, while others ask over 20, and some ask over 100 depending on patient responses. There is significant heterogeneity in the information the assessments collect and how it is used to generate patient placement decisions. Among the 29 assessments examined, there are 8 different algorithms or instructions on how to translate information from assessments into level of care recommendations. CONCLUSIONS: The differences among the ASAM-based assessments examined in this paper suggest a need to implement fidelity standards, enhance training, and create resources to help systems create and utilize assessment and patient placement tools that are consistent across the SUD treatment field.

Prior Authorization for Opioid Use Disorder Versus Pain Medications: Lessons Learned for Parity Enforcement.

OBJECTIVE: This study characterized the use of prior authorization for opioid use disorder medications as compared with that for opioid pain medications in the United States among Medicare Part D plans. METHOD: Medicare Part D formulary data from 2017-2019 were used to describe differences in prior authorization between opioid use disorder medications and opioid pain medications. RESULTS: In 2017, 72% of Medicare Part D formularies required prior authorization for brand buprenorphine-naloxone, whereas 6% of formularies required prior authorization for brand oxycodone. In 2019, 3% of formularies required prior authorization for brand buprenorphine-naloxone, whereas 16% of formularies required prior authorization for brand oxycodone. Throughout the study period, other formulary restrictions such as quantity limits were similar for both medications. CONCLUSIONS: The disparate use of prior authorization in 2017 for opioid use disorder medications as compared with opioid pain medications suggests that formulary decision making may be inconsistent between medications used to treat substance use disorders and those used to treat pain. If Part D formularies publicly released their decision-making criteria, then there would be a greater understanding of why prior authorization was differentially applied. Greater transparency would help ensure that formulary decisions are not the result of biases and stigma toward substance use disorders.

"The assessment really helps you with the first step in recovery." What do clients think substance use disorder treatment intake assessments should look like?

Background: In general, research has found that patient-centered substance use disorder treatment is positively correlated with improved patient outcomes. However, little research has examined what factors make intake assessments-the first step in addiction treatment-patient-centered. Methods: We conducted interviews with 30 Medicaid-enrolled individuals who received addiction treatment in California about their experiences with the intake assessment process. Results: Participants reported that the intake assessment process evoked strong feelings, both positive and negative. Some participants said that answering detailed questions about their substance use, mental health, and social relationships, for example, was cathartic and gave them helpful insights. Other participants found the questions invasive, exhausting, and anxiety provoking. Participants also emphasized how critical it is for the person conducting the assessment to be supportive, nonjudgmental, and attentive. Participants recommended delaying the comprehensive assessment because they did not feel physically or emotionally ready to complete the intake. Conclusions and recommendations: Patients' introduction to addiction treatment is typically the intake assessment. By understanding how patients experience intake assessments, providers can make the process more patient-centered, which may lead to improved patient outcomes.

How to Mitigate the Mental Health Care Consequences of the COVID-19 Financial Crisis.

The COVID-19 pandemic has led to record unemployment claims and a weakened U.S. economy. This column reviews results of past research to examine how a recession might affect behavioral health and the treatment of mental and substance use disorders and suggests potential policy solutions. Despite increases in suicide and substance use, losses in employment-related health insurance could dampen treatment seeking. Federal, state, and local officials should be vigilant regarding suicide prevention. Individuals who lose employee insurance coverage should be protected through insurance marketplaces and Medicaid outreach and enrollment. Public and private coverage of telehealth, which has already been expanded, should continue beyond the pandemic. Federal support for community behavioral health organizations should continue to offset state and local budget cuts and ensure provision of needed treatment. The capacity of social services should be expanded as well as systems that facilitate client connection to social services.

Adherence to buprenorphine treatment guidelines among individuals with an opioid use disorder who have private insurance.

BACKGROUND: Although treatment of opioid use disorders (OUD) with medications is expanding, the extent to which practitioners are prescribing medications following best practices has received little attention. OBJECTIVE: The aim of this study was to determine the extent to which privately insured patients being treated for OUD with buprenorphine were treated in a manner consistent with practice guidelines. DESIGN: Longitudinal analyses of a large commercial claims dataset from 2012 to 2016. PARTICIPANTS: We analyzed data for 38,517 patients with an OUD diagnosis continuously enrolled for 3 months prior to and 6 months after an initial buprenorphine or buprenorphine-naloxone prescription fill. MAIN MEASURES: We evaluated whether practitioners tested patients for hepatitis B, hepatitis C, HIV, and liver function; how often they received urine drug screens; the frequency of outpatient visits; and the extent to which they filled prescriptions for buprenorphine for at least 6 months. KEY RESULTS: Practitioners tested approximately 4.7% of patients for hepatitis B, 6.5% for hepatitis C, and 29.3% for HIV; they tested 8.0% for liver functioning; and gave 33.3% urine drug tests. Approximately 76% of patients had at least one outpatient visit for their OUD. Among those with at least one visit, the mean number of visits was 7.38. After the initial prescription, 47.5% stayed on buprenorphine for at least 6 months. CONCLUSIONS: A large portion of privately insured patients receiving buprenorphine for OUD did not receive care consistent with guidelines.

Comparison of Medicaid Reimbursements for Psychiatrists and Primary Care Physicians.

OBJECTIVE: This study aimed to investigate whether state Medicaid programs systematically reimburse psychiatrists less than they reimburse primary care physicians. METHODS: This study used outpatient Medicaid claims data from 2014 for 11 U.S. states. Claims with a primary behavioral health diagnosis (i.e., mental or substance use disorder) and an evaluation and management procedure code of 99213 or 99214 were identified. These are the most frequently used procedure codes by both psychiatrists and primary care physicians when treating patients with mental and substance use disorders. Average reimbursements were compared for nonfacility claims submitted by psychiatrists and primary care physicians. RESULTS: In 9 states, psychiatrists were reimbursed less on average than primary care physicians. In one state, reimbursements were nearly equivalent. CONCLUSIONS: Disparities in reimbursements across specialties may reduce access to psychiatric specialty care through Medicaid and are inconsistent with the Mental Health Parity and Addiction Equity Act.

Association of Formulary Prior Authorization Policies With Buprenorphine-Naloxone Prescriptions and Hospital and Emergency Department Use Among Medicare Beneficiaries.

Importance: Prior authorization requirements may be a barrier to accessing medications for opioid use disorder treatment and may, therefore, be associated with poor health care outcomes. Objective: To determine the association of prior authorization with use of buprenorphine-naloxone and health care outcomes. Design, Setting, and Participants: This comparative interrupted time series analysis examined enrollment and insurance claims data from Medicare beneficiaries with an opioid use disorder diagnosis or who filled a prescription for an opioid use disorder medication between 2012 and 2017. Over this period, 775 874 members were in 1479 Part D plans that always required prior authorization, 113 286 members were in 206 plans that removed prior authorization, 189 461 members were in 489 plans that never required prior authorization, and 619 919 members were in 485 plans that added prior authorization. Data analysis was performed from April 2019 to February 2020. Exposures: Removal or addition of prior authorization and new prescriptions filled for buprenorphine-naloxone. Main Outcomes and Measures: Buprenorphine-naloxone use, inpatient admissions, emergency department visits, and prescription drug and medical expenditures. Results: The study population in 2012 included 949 206 Medicare beneficiaries (mean [SD] age, 57 [15] years; 550 445 women [58%]). Removal of prior authorization was associated with an increase of 17.9 prescriptions (95% CI, 1.1 to 34.7 prescriptions) filled for buprenorphine-naloxone per plan per year, which is a doubling of the number of prescriptions, on average. Each prescription filled was associated with statistically significant decreases in adverse health care outcomes: substance use disorder-related inpatient admissions decreased by 0.1 admission per plan per year (95% CI, -0.2 to -0.1 admission per plan per year), and substance use disorder-related emergency department visits decreased by 0.1 visit per plan per year (95% CI, -0.13 to -0.03 visit per plan per year) (all P < .001). Combining these results, removal of prior authorization was associated with a reduction in substance use disorder-related inpatient admissions by 2.0 admissions per plan per year (95% CI, -4.3 to -0.1 admissions per plan per year) and substance use disorder-related emergency department visits by 1.4 visits per plan per year (95% CI, -3.2 to -0.1 visits per plan per year). Conclusions and Relevance: Removing prior authorization for buprenorphine-naloxone was associated with an increase in the medication use and decreases in health care utilization and expenditures.

Access to and Engagement in Substance Use Disorder Treatment Over Time.

OBJECTIVE: This study evaluated whether access to and engagement in substance use disorder treatment has improved from 2010 to 2016. METHODS: Data submitted by commercial and Medicaid health plans, representing over 163 million beneficiaries from 2010 to 2016, were analyzed. RESULTS: For commercial plans, identification increased (from 1.0% to 1.6%, p<0.001), the initiation rate declined (from 41.9% to 33.7%, p<0.001), and the engagement rate also declined (from 15.8% to 12.1%, p<0.001). The decline in the initiation and engagement rates could not be explained by the increasing identification rates. For Medicaid plans, the identification rate increased (from 3.3% to 6.7%, p<0.001), and the initiation and engagement rates were unchanged. CONCLUSIONS: Although an increasing proportion of health plan members are being identified with substance use disorders, the majority of these individuals are not engaging in treatment.

Increasing Access to Opioid Use Disorder Treatment: Assessing State Policies and the Evidence Behind Them.

OBJECTIVE: Combatting the opioid epidemic requires systemic policy changes that address the underutilization of medication-assisted treatment, a therapy that is effective in treating opioid use disorder. In this study, we present approaches used in five states to increase medication-assisted treatment financing and access. METHOD: We conducted case studies in five U.S. states, interviewing key informants and reviewing the published literature and unpublished documents. RESULTS: In these states, Medicaid expansion was the most significant lever available to expand financing and access to medication-assisted treatment. Other key levers include Medicaid Section 1115 SUD demonstrations, State Targeted Response to the Opioid Crisis and State Opioid Response grants, state contracting mechanisms, and other state regulations. CONCLUSIONS: States in this study reported substantial progress in increasing access to medication-assisted treatment, but empirical evidence of their effects is still emerging.

Opioid medication discontinuation and risk of adverse opioid-related health care events.

BACKGROUND: Between 2012 and 2017, the United States dramatically reduced opioid prescribing rates. While this may be appropriate given the opioid epidemic, there has been little research to guide the clinical practice of discontinuing patients from opioid medications and opioid death rates have continued to increase. OBJECTIVE: To determine the relationship between time to opioid discontinuation and the risk of an opioid-related emergency department visit or hospitalization among high dose opioid users. DESIGN: We applied Cox proportional hazard models to 2013-2017 Medicaid claims data to research this relationship. PARTICIPANTS: Medicaid beneficiaries in Vermont who filled prescription opioids at high daily doses (at least 120 morphine milligram equivalents) for 90 or more consecutive days and who subsequently discontinued opioid prescriptions (n = 494). MAIN MEASURES: The outcome was an opioid-related adverse event defined as an emergency department visit or hospitalization with a primary or secondary diagnosis of opioid poisoning or substance use disorder. KEY RESULTS: The median length of time to discontinuation was 1 day indicating that half of patients had no dose reduction prior to discontinuation. 86% of patients discontinued within 21 days (considered rapid tapering in recent clinical guidelines). 49% of members had an opioid-related hospitalization or emergency department visit. After controlling for sociodemographic and clinical factors, each additional week of discontinuation time was associated with a 7% reduction in the probability of having opioid related adverse event (p < 0.01). Although 60% of members had a diagnosed substance use disorder prior to tapering, <1% of beneficiaries were transitioned onto an opioid use disorder medication. CONCLUSIONS: Faster rates of opioid tapering were associated with a greater probability of adverse events and many patients discontinued opioids suddenly, with no dose reduction. Additional clinical guidance, research, and interventions are needed to ensure that patients' opioid prescriptions are discontinued safely.

Cost-Effectiveness of Preventing Depression Among At-Risk Youths: Postintervention and 2-Year Follow-Up.

OBJECTIVE: Youth depression can be prevented, yet few programs are offered. Decision makers lack cost information. This study evaluated the cost-effectiveness of a cognitive-behavioral prevention program (CBP) versus usual care. METHODS: A cost-effectiveness analysis was conducted with data from a randomized controlled trial of 316 youths, ages 13-17, randomly assigned to CBP or usual care. Youths were at risk of depression because of a prior depressive disorder or subthreshold depressive symptoms, or both, and had parents with a prior or current depressive disorder. Outcomes included depression-free days (DFDs), quality-adjusted life years (QALYs), and costs. RESULTS: Nine months after baseline assessment, youths in CBP experienced 12 more DFDs (p=.020) and .018 more QALYs (p=.007), compared with youths in usual care, with an incremental cost-effectiveness ratio (ICER) of $24,558 per QALY. For youths whose parents were not depressed at baseline, CBP youths had 26 more DFDs (p=.001), compared with those in usual care (ICER=$10,498 per QALY). At 33 months postbaseline, youths in CBP had 40 more DFDs (p=.05) (ICER=$12,787 per QALY). At 33 months, CBP youths whose parents were not depressed at baseline had 91 more DFDs (p=.001) (ICER=$13,620 per QALY). For youths with a currently depressed parent at baseline, CBP was not significantly more effective than usual care at either 9 or 33 months, and costs were higher. CONCLUSIONS: CBP produced significantly better outcomes than usual care and was particularly cost-effective for youths whose parents were not depressed at baseline. Depression prevention programs could improve youths' health at a reasonable cost; services to treat depressed parents may also be warranted.

The importance of identification when measuring performance in addiction treatment.

Background: Identifying and effectively treating individuals with substance use disorders (SUDs) is an important priority for state Medicaid programs, given the enormous toll that SUDs take on individuals, their families, and their communities. In this paper, we describe how the Healthcare Effectiveness Data and Information Set (HEDIS) measure "Identification of Alcohol and Other Drug Services" can be used, along with eligible population prevalence rates, to expand states' ability to track how well their Medicaid programs identify enrollees with SUDs and link them with treatment (measured by initiation and engagement performance measures). Methods: We use the 2009 Medicaid MAX data on utilization and enrollment along with information from the National Survey of Drug Use and Health (NSDUH) to obtain state-level estimates of alcohol and drug abuse and dependence among Medicaid beneficiaries for 7 illustrative states. We calculate identification, initiation, and engagement measures using specifications from the National Committee on Quality Assurance (NCQA). Results: NSDUH data showed that the eligible population prevalence rate (the average rate of alcohol or drug abuse or dependence) among the 7 states was 10.0%, whereas the average identification rate was 2.9%. The gap between the prevalence and identification rates ranged from 5.1% to 11.0% among the 7 states. The initiation rates ranged from 36.9% to 57.1%. The states' engagement rates ranged from 11.8% to 31.1%, although rates differ by age, gender, and race/ethnicity in some states. Conclusion: Including identification along with initiation and engagement measures allows states to determine how well they are performing in a more complete spectrum from need, to recognition and documentation of enrollees with SUDs, to initiation of treatment, to continuation of early treatment.