ADOPTING EVIDENCE-BASED MEDICALLY

ASSISTED TREATMENTS IN SUBSTANCE ABUSE

TREATMENT ORGANIZATIONS: ROLES OF
LEADERSHIP SOCIALIZATION AND FUNDING
STREAMS

TERRY C. BLUM
Georgia Institute of Technology

CAROLYN D. DAVIS
Morehouse College

PAUL M. ROMAN
University of Georgia

ABSTRACT
This paper examines the organizational adoption of medically
assisted treatments (MAT) for substance use disorders (SUDs) in a
representative sample of 555 US for-profit and not-for-profit treatment
centers. The study examines organizational adoption of these
treatments in an institutionally contested environment that traditionally
has valued behavioral treatment, using sociological and resource
dependence frameworks The findings indicate that socialization of
leadership, measured by formal clinical education, is related to the
adoption of MAT. Funding patterns also affect innovation adoption,
with greater adoption associated with higher proportions of earned
income from third party fees for services, and less adoption associated
with funding from criminal justice sources. These findings may
generalize to other social mission-oriented organizations where
innovation adoption may be linked to private and public benefit values
inherent in the type of socialization of leadership and different patterns
of funding support.

INTRODUCTION
The treatment of substance use disorders (SUDs) has
grown rapidly since the 1970s, now comprising a
significant component of the U.S. health care industry with
a gross expenditure on SUD treatment in 2006 estimated at
38 JHHSA SUMMER 2014

over $20 billion (Mark, Levit, Vandivort-Warren, Coffey &

Buck. 2007; Kimberly & McLellan, 2006). Together with
the entire health care industry (Timmermans & Kolker,
2004), the sector dealing with the treatment of SUDs is
under substantial pressure to adopt evidence-based
practices. Among the innovative evidence based practices
that can enhance outcomes of individuals’ struggles with
abuse of psychoactive substances is the use of several
different pharmaceuticals or medication-assisted treatments
(MAT). Yet, there are organizational leadership and
ideological barriers to the incorporation of MAT in SUD
treatment.
In this paper, we examine the effects of SUD
treatment center directors’ background and center funding
sources on the organizational utilization of MAT in a
nationally representative US sample of substance abuse
treatment centers. We attempt to understand variation in
the adoption of MAT across treatment centers in a
treatment environment that has long been centered upon the
value of behavioral interventions, abstinence, and
particularly, 12-step approaches. We utilize the lens of
formal educational socialization that influences
professional identity (Hekman, Steensma, Bigley &
Hereford, 2009), social capital (Lin, 2001), and resource
dependence (Pfeffer & Salancik, 1978) to understand the
extent to which they explain why some treatment centers
adopt MAT while others do not. We focus on the
relationship between the professional studies of treatment
centers’ executive directors, in terms of socialization
dimensions, linking it to their organization’s MAT
adoption. We also examine the relationship between
resource dependence through mixes of public and private
benefit funding (Young, 2007) and MAT adoption.
Before presenting our hypotheses and reporting the
results of our analyses, we describe the historical context of
SUD treatment in which we outline “medicalized,” rather
JHHSA SUMMER 2014 39

than punitive and social tolerance responses to SUD;

describe what might be considered a treatment paradigm of
abstinence achieved through 12-step programs and
behavioral therapies; and, compare SUD and general
medical treatment, setting the stage for understanding the
context for organizational adoption of MAT as an
institutionally contested innovation.

SUBSTANCE ABUSE TREATMENT

Medicalization of SUD
During the 20th century, sociologists highlighted the
medicalization of formerly deviant activity within
American culture (Roman, 1980; Conrad & Schneider,
1980; Conrad & Leiter, 2004). Medicalization is one of
three alternative societal reactions to problematic use of
alcohol or other drugs. The second is generalized social
tolerance and the absorption of the consequences of these
behaviors into social functioning. This reaction prevailed
throughout human history until the early 19th century. The
third alternative is negative sanctions and punishment,
found in modest degree in reactions to the disruptive and
non-productive consequences associated with public
drunkenness over recorded history. Beginning in the 19th
century, these negative sanctions attracted major
investment of social resources.
Drinking emerged as a social problem in the U.S. in
the 1820s, and punishment first to excessive use and then to
all use became the prime reaction (Clark, 1976). The U.S.
eventually legislated nationwide prohibition, and this social
attitude spilled over to other drug use that became
prominent in the late 19th and early 20th centuries and
persists today. Incomplete and ambivalent medicalization
of illegal drug use is currently represented by sustained
punitive attitudes and practices coupled with official
policies advocating medicalization and treatment.
40 JHHSA SUMMER 2014

Treatment Paradigm
The social invention and refinement of Alcoholics
Anonymous (AA) from 1935 to 1955 marked the
emergence of a recognizable treatment for alcoholism
within American culture (Roman, 1988). Its elements
include self-reliance, populism (offering “membership” to
anyone motivated to participate), organizational poverty
(refusing money except for bare necessities),
decentralization/localism (core structure is the “group”),
bureaucratic rules (Twelve Steps and Twelve Traditions,
unchanged for 75 years), isolation (no supportive ties with
any other organizational structure) and medicalization
(belief that the root of “loss of control” is a biomedical
abnormality). Through these fundamentalist and cost-free
elements, AA offers the private good of abstinence and
“sobriety” to individuals, which produces a public good by
reducing individual, familial, community, and societal costs
of alcoholism.
In the mid-1940s, an affiliate non-profit organization,
informally and tightly coupled with AA, was created: the
National Council on Alcoholism, which had as its singular
goal, “the recognition and treatment of alcoholism as a
disease like any other” (Beauchamp, 1980). This
“independent” collectivity strived to create a hospitable and
respectable environment for the growth and
institutionalization of the 12-step model. In 1970, these
nascent interests gained a spectacular infusion of resources
through federal legislation that provided what seemed like
massive funds for treatment and research, setting the stage
for organizational legitimacy (Winer, 1981).
A collection of isomorphic alcoholism treatment
centers emerged supported from the mid-1970s to the late-
1980s by health insurance and public grants. The absence
of evaluative or cost-benefit data to justify to third-party
payers the expensive month-long inpatient treatment
JHHSA SUMMER 2014 41

regimen common across nearly all these private programs

led to sharp cutbacks in insurance coverage and eventual
limitation of coverage to outpatient care.
In the early 1990s, forty percent of the exclusively
inpatient programs closed as managed care limited third
party payments for treatment (Shane, Blum & Roman,
1997). While it might be expected that this form of
enterprise would disappear, or perhaps survive in a form
based only on public support, neither of these outcomes
occurred. Instead a more heterogeneous collection, based
on abstinence and 12 step programs, emerged.
Further, these changes were accompanied by shifts in
public policy that rather quickly merged monies for the
treatment of alcoholism, opiate addiction, and other
substance abuse into what became, by the 21st century, a
single set of agencies for the treatment of all substance
abuse. With this merger, the patient population came to
include a significant element of socially dependent people
with considerable contact with the criminal justice system
whose recovery required far more assistance than simply
abstinence from drugs and alcohol.
These challenges describe the entry and/or emergence
of a new form of treatment center leadership, demonstrated
by embracing a treatment philosophy that surrounded the
basic treatment of addiction with “wraparound services”
addressing needs across psychological, family, housing,
employment and legal realms. This service expansion
increased the support for recovery as well as provided
opportunities for effective social functioning in post-
treatment roles. Curiously, this foreshadowed
contemporary emphases on the need to re-define primary
care in a holistic manner in the form of a “medical home.”
Within the SUDs specialty, a new paradigm was put forth,
a distinct contrast to the earlier 12-step adage that all
personal troubles would improve if the AA affiliate
continued to “work the program.” In sharp contrast to the
42 JHHSA SUMMER 2014

earlier rigid adherence to a single approach, the watchword

of this new paradigm of SUD treatment is flexibility in
service offerings and in ever-changing strategies for
generating patient referrals.
Several principles of contemporary treatment with AA
roots do however persist, even among those who deny
adherence to that treatment ideology. These include the
continued belief in abstinence from alcohol and drugs as
the only acceptable criterion for treatment success, belief in
alcoholism and addiction as biologically rooted, and
continued openness to spirituality as a key to the recovery
process.

SUD and General Medical Care

This leads to several important comparisons between
general medical care and SUD treatment. First, using the
outcome criterion of sustained post-treatment abstinence,
SUD treatment shows spectacularly discouraging rates of
“success,” leading to high rates of treatment recidivism.
Together, “relapse” and recidivism support beliefs of
pessimism about SUD treatment. Second, given the
linkages between drug use and the legal system, a
substantial number of referrals enter treatment without
believing they are ill, i.e. without the self-image of being
“addicted” and in need of treatment. Third, engagement in
treatment is problematic, with a substantial proportion of
patients entering treatment and quickly leaving, or leaving
before completing the prescribed regimen. Fourth, patient
problems and maintaining quality of care may be
exacerbated by staff problems, with SUD treatment
programs chronically underfunded and often understaffed,
with relatively low wages and benefits and high rates of
turnover (McLellan, Cerise & Kleber, 2003).
It is in this context of (1) a dominant abstinence
paradigm and (2) striking contrasts between SUD treatment
and general medicine that we focus upon the leadership of
JHHSA SUMMER 2014 43

SUD treatment organizations and funding mix of SUD

treatment organizations to understand the inclusion of
MAT as an option across treatment centers.

HYPOTHESES

SUD Treatment Center Leadership

How can such organizations attract leaders? Perhaps
surprisingly, our research demonstrates that leaders often
stay for long periods within these organizations and many
maintain high morale and involvement in what they do. If
we combine the history of the type of organization with the
organizational conditions that have been described, social
entrepreneurship, the combining of social mission with
commercial impulses, is an apt description of leadership
job requirements. Leadership may be drawn to, and
sustained by this work, through the modest improvement
observed in some and dramatic improvement observed in a
few. Further understanding may be captured by looking at
the identity formation among leaders who apparently
respond positively to seemingly low levels of objective
rewards.
There are two approaches in the literature on
professions to understanding how professional identity, an
aspect of personal and social identity that develops in
professional personnel as a result of their work activities,
is established. The trait approach proposes that
professional identity is defined by specific characteristics
that describe the profession (Kultgen, 1988), while the
phenomenological or “folk” approach proposes that
professional identity is established by activities in which
persons engage (Miller, 1998; Friedson, 1983). The
activities described here in the brief history of SUD
treatment not only present evidence for viewing these
leaders in a context of social entrepreneurship, but also
provide a “folk” approach to better understanding how
44 JHHSA SUMMER 2014

these leaders are socialized and develop professional

identity. One of the sources of socialization and
development of professional identity, for these leaders can
be found in the types of formal education they have
received. Social categorization theory (Turner, Hogg,
Oakes, Reicher & Wetherell, 1987) suggests that
differential socialization that exposes potential
organizational leaders to the paradigms that are associated
with SUD treatment, to an emphasis on organizational
management, to educational disciplines, or their own
indigenous experiences with recovery are likely to be
influenced by the norms and identities adopted by others
who have shared their socialization experiences.
We next examine how this fits with adoption behavior.
Much of the research on diffusion of innovation focuses on
how structures and processes within organizations affect
innovation dispersion through a population of potential
adopters. Economic literature tends to answer this question
on the basis of markets and information availability, while
sociological explanations focus on conformity to
environmental expectations.
Ansari, Fiss & Zajac (2010) provide an integrative
model that conceptualizes the pattern of innovation
diffusion as an outcome of the technical, cultural and
political fit between the innovation itself and characteristics
of the adopters, with the demand for innovation being
associated with the organization’s ability to recognize the
value of an innovation associated with organizational
factors such as the background and experience of decision
makers (Wejnert, 2002). Diffusion may be enhanced by
the content of the socialization of organizations’ leaders.
Professional identities are constructed through the course of
training and residency programs (Pratt, Rockmann &
Kaufmann, 2006), professional identities have implications
for performance (Hekman, Steensma, Bigley & Hereford,
2009, Hekman, Bigley, Steensma & Hereford, 2009), and
JHHSA SUMMER 2014 45

social and cognitive boundaries of professional groups can

retard diffusion in communities of practice, which tend to
be highly institutionalized (Ferlie, Fitzgerald, Wood &
Hawkins, 2005).
Some of the careers and educational socialization of
the executive directors of SUD treatment centers are
typified by engagement in various types of formal clinical
education that impart training for diagnosing and treating a
wide range of behavior disorders. Other careers are
typified by participation in the “folk” history of the field,
with educational experiences that either did not include
broad counseling preparation or advanced degrees.
Included in this category are those who engaged in
narrower certification programs for exclusive counseling of
SUD patients.
Through treatment-related formal education, center
directors may have developed a network of contacts
different than those without this educational socialization,
including those who have clinical degrees but do not work
in SUD treatment. These leaders are more likely to share
professional identities with others who engage in treatment
of clients with disorders other than SUD, and who routinely
utilize medications as part of treatment interventions.
Leaders without clinical degrees would be less likely to
develop these diverse ties (Ferlie, Fitzgerald, Wood &
Hawkins, 2005). In addition to potentially greater
influence from clinicians outside SUD treatment, leaders
who engaged in various types of formal clinical education
also have the potential to develop a network of distant ties,
and therefore are more likely to be exposed to the value in
adopting new and novel ideas (Perry-Smith, 2006; Perry-
Smith & Shalley, 2003).
This is further explicated through the concept of social
capital (Lin, Cook & Burt, 2001), which, in the context of a
SUD treatment organization, is greater for those leaders
who pursued clinical degrees than those who did not.
46 JHHSA SUMMER 2014

Networks of social relationships stemming from this capital

investment have embedded resources associated with
increased information, influence, social credentials, and
reinforcements (Lin, 2001) that in turn could enhance the
adoption of new combinations of ideas and resources.
Specifically, the increase in information flow can provide
access to documented benefits of innovations and evidence
based practices. The increase in influence and social
credentials from social ties could provide greater
accessibility to valued resources and provide legitimacy
and credibility beyond personal capital. Social
relationships where information and influence are shared
reinforce identity and underline its value through the
recognition that is received. Thus, through these
mechanisms facilitated by social capital, relevant formal
education among administrators of SUD treatment centers
can have an effect on adoption of MAT in SUD treatment.
Adopting institutionally contested (Fiss & Zajac,
2004; Sanders & Tuschke, 2007) MAT innovations for
treatment of SUD is related to the social capital of
educational socialization and associated professional
identity (Ferlie, Fitzgerald, Wood & Hawkins, 2005), with
executive directors who have formal educational
experiences in clinically relevant disciplines having
“mindlines” that increase the likelihood of adoption of
MAT in SUD treatment organizations. Therefore, we
hypothesize:

H1: Across SUD treatment organizations, there will be a

relationship between the extent of the adoption of MAT and
the educational experience of the organizational leaders
such that there will be greater adoption among those with
clinical education in relevant disciplines.
JHHSA SUMMER 2014 47

Environmental Context of Resource Dependence

In their definition of social entrepreneurship,
Murphy and Coombes (2009) emphasize the importance of
context. They describe environmental context in terms of
mobilization or large scale public support of the social
entrepreneurial endeavor. In their description, support is
actualized as a convergence of social, economic and
environmental resources to facilitate identification of
innovative opportunities. The source of funding to sustain
the organization’s core technology is one dimension of the
environmental context that influences managerial strategies
such as the extent of adoption of innovations.
Resource dependence theory argues that
organizations need to take in resources from entities
external to the organization, and organizations that control
resources have power over those that need these resources
(Pfeffer & Salancik, 1978). Thus the source of a health
care organization’s resources may be more important in
understanding whether new practices are adopted than the
legal status or ownership of the organization. Whether
socially entrepreneurial organizations are privately or
publicly owned, they must acquire resources to realize their
mission.
Bozeman and Straussman (1983) argue that an
understanding of resource dependence helps us understand
the degree of control exerted by organizational sources of
funding. Managerial strategies used to reach organizational
objectives are influenced by resource acquisition processes
regardless of organizational ownership - government, non-
profit or for-profit; or their business model - classic non-
profit, for-profit or hybrid (Elkington & Hartigan, 2008).
The resource dependence of SUD treatment centers may
trump the “cui bono” (Blau and Scott, 1962), or who
benefits, approach to understanding organizational
behavior.
48 JHHSA SUMMER 2014

In an undercapitalized social entrepreneurial

context, an organization depending primarily on public
funds that are scarce and highly competitive may be
reluctant to embrace new and different values that may
accompany an innovative way of addressing a social need.
As Bozeman and Slusher (1979) argue, resource scarcity
can result in less willingness to consider new opportunities.
In both undercapitalized for-profit and non-profit
organizations, where resources are unpredictable, adoption
of innovation could be stifled in favor of efficiency norms,
with an emphasis on risk avoidance strategies focused on
operating at full capacity by delivering traditional services,
at the lowest unit price, to as many clients as possible
(Bozeman and Straussman, 1983).
One of the dilemmas faced by leaders in a resource
constrained context when deciding whether to adopt an
innovation is aligning the values of the new innovation
with values held by those providing funding. Resource
dependency theory suggests the importance of such
alignment for organizational survival. Incompatible new
values may be introduced to the status quo, such as
introducing private good-type innovations in an
environmental context that values public goods. For
example, when funders value a particular treatment for
SUD patients that has been perceived historically as
providing a public good, such as a 12-step approach versus
new MAT perceived as providing a private good,
innovation adoption may be repressed.
In a normative theory of nonprofit finance, the
nature of goods and services provided is associated with
benefits that influence who will pay for them (Young,
2007), with the organizational income portfolio associated
with goods and services provided mediated by strategic
adjustments of organizations. In a study of nonprofit
organizations in subcategories of the National Taxonomy
of Exempt Entities (NTEE) of the arts, health, and human
JHHSA SUMMER 2014 49

services the proportion of revenues derived from earned

income or fees for services to specific individuals is lowest
for services deemed public benefits, highest for those
deemed private, and in the middle for those that have
mixed benefits (Fischer, Wilsker &Young, 2010).
Consequently, it may be that SUD treatment
organizations receiving greater portions of their funding
from sources that ordinarily provide private benefits, as
fees for services to specific individuals, are less hesitant
and more willing to embrace change than those that provide
block resources as part of its mission for societal good.
Therefore,

Hypothesis 2: Across SUD organizations, there will be a

positive relationship between the extent of the adoption of
MAT and proportion of funding providing private, fee for
services, benefits to specific individuals.

METHODS

Hypothesis 1 examines the education of the

executive director and its relationship to an organizational
level dependent variable, adoption of evidence based MAT,
reflecting diffusion of these innovations throughout the
SUD treatment field. Hypothesis 2 examines the
relationship between an organizational level dependent
variable, the percent of earned income from fees and
services that provide private benefits to specific
individuals. The hypotheses are tested using data from 555
SUD treatment centers collected over an 18-month period
from late 2002 through early 2004 in the United States
(US) as part of a larger National Treatment Center Study.
Even though there are several waves of data collected in the
larger project, different questions were asked in the
different waves. The fourth wave of data is used for these
analyses because it includes variables on the range of
50 JHHSA SUMMER 2014

center ownership and funding sources needed to test our

hypotheses.
The SUD treatment centers used in the study were
drawn from a two-stage stratified random sample of
geographic areas throughout the U.S. Counties in the U.S.
were allocated to strata based on population, then sampled
within strata. The total population of treatment centers for
the selected counties was compiled from a variety of
sources including federal and state directories, yellow page
listings, employee assistance program referral directories,
survey sample call lists, and other available sources. These
centers are facilities offering treatment for alcohol and drug
problems with a level of care at least equivalent to
structured outpatient programming as defined by the
American Society of Addictive Medicine (ASAM). Since
our program population is defined as community based
treatment programs where all members of the community
are eligible to seek services, our sample does not generalize
to Veterans Administration programs that limit their access
to veterans (Harris, Humphreys, Bowe & Kivlahan, 2009)
or criminal justice programs that limit access to prisoners
(Taxman, Perdoni & Harrison, 2007) that are outside the
scope of our sampling frame.
On-site interviews were conducted with 714
individuals leading treatment centers (84% response rate).
The analysis of hypotheses was conducted using complete
responses for the variables identified below, providing a
minimum sample of 555 centers (77% of those interviewed,
and 68% of organizations in the sampling frame). Logistic
regression analysis of whether a center was excluded from
the analysis because of list wise deletion of partially
missing information, or included because all study
variables were complete was used to assess whether the
linear combination of independent and control variables
included in our analyses affected our results. None of the
variables was significantly related to inclusion or exclusion,
JHHSA SUMMER 2014 51

suggesting that the cases that are missing are missing at

random and are not biasing our results (Goodman and
Blum, 1996).

Measures
Adoption of Medication-Assisted Treatment: This
variable measures whether each of 4 MATs is used as a
treatment option at the treatment center. The respondents
were asked if each of the 4 “evidence based” medications –
Disulfiram (widely known as Antabuse), Naltrexone,
Buprenorphrine, and Selective Serotonin Reuptake
Inhibitors, were used to treat clients in their center. These
medications have been shown in research studies to be
effective and have been accepted as evidence based
practices, but have not crossed the chasm to be adopted by
a large number of physicians or SUD treatment programs
(Knudsen, Abraham & Roman, 2011; Roman, Abraham, &
Knudsen, 2011). If the center used the treatment for
patients in the categories included in the approval provided
by the Food and Drug Administration (FDA), the response
was coded as a “1.” If the center did not use the treatment,
the response was coded as “0.” When factor-analyzed, the
four treatment variables for the centers in this study loaded
onto one factor which had an eigenvalue of 1.92. All four
treatment variables were also significantly correlated with
each other at the significance level of .01. We calculated a
MAT technological adoption index for each center by
summing the response codes (0 or 1) for the four treatments
for each center. The range of the extent of adoption is 0-4,
with relatively low extensiveness of adoption indicated by a
mean of 1.07. Forty-two percent of the centers used none
of the MATs, while 28.6% used 1, 15.9% adopted 2, 11.2%
adopted 3, and 1.4% adopted all 4 of them.
The FDA approved Disulfiram for use in the
treatment of alcoholism in 1951. Despite the relatively
early date of its approval for use, the nature of Disulfiram’s
52 JHHSA SUMMER 2014

action has never become widely accepted by treatment

specialists nor has it been accepted within the normative
culture of SUD treatment organizations, although it is an
evidence-based practice and recommended by the National
Institute for Drug Abuse (NIDA).
Naltrexone has been found effective in the
treatment of alcohol dependence and for opiate
dependence, and has been approved for use by the FDA
since 1994. Selective Serotonin Reuptake Inhibitors
(SSRIs) have been approved by the FDA for the treatment
of depression since the late 1980s. Their use in SUD
treatment is for co-occurring psychiatric problems.
Buprenorphine was approved by the FDA for use in the
treatment of opioid dependence in 2002. The data for this
study were collected relatively soon after the drug’s FDA
approval. Disulfiram was used in 25.7% of the centers,
while naltrexone was used in 21.7%, SSRIs were used in
48.4% and buprenorphine was used in 7% of the treatment
organizations.
Clinically Relevant Education: This characteristic
of the SUD treatment center leader is an indicator of one
form of formal socialization. It is measured as a
combination of the highest degree held and the field of
study. Respondents were given 5 categories from which to
choose. The five categories provided were coded as
follows: “1”- less than Bachelor’s; “2” - Bachelor’s; “3”-
Master’s; “4” – Doctorate; “5” - M.D. Five educational
category variables were created to distinguish the types as
well as the level of education. These five variables are
labeled 1) Bachelor’s or less, 2) Masters in Business, 3)
Master’s in Social Work and Master’s in
Psychology/Counseling, 4) Master’s in other fields, and 5)
Ph.D. or M.D. For this analysis, the Master’s in Social
Work/ Masters in Psychology/Counseling, nursing, and
MD or Ph.D., typically degrees that include formal
education and internships, are considered treatment
JHHSA SUMMER 2014 53

relevant degrees and were coded “1” and the variable was
named “Clinical Degree”, while the remaining categories
were coded “0”. Those with Bachelor’s degrees or less, or
advanced degrees in a field unrelated to clinical practice are
coded “0”. Forty-five percent of the executive directors
have clinically relevant socialization.
Public/ Private Funding: To measure the
organizational context of resource dependency, we
examined the funding sources for these SUD treatment
centers. We measured the proportion of public funding
received by the SUD treatment center as follows: Funding
from the public criminal justice system; funding from
federal block grants; other funding from each of federal,
state and county sources. The proportion of funding that
provides fees for services for individuals, considered
private benefit funding, include: Funding from private or
commercial insurers; payments for individuals from
Medicare and from Medicaid; payments by Health
Maintenance Organizations (HMOs); and client payments.
This information was provided in the on-site interview and
verified by coders. The proportion for each category was
calculated with the total organizational revenues for the
previous year as the denominator, and the revenue
attributed to the category as the numerator. On average,
93% of the center revenues come from the sources listed,
with 48% coming from public sources and 52% coming
from private or “voucher” based, fees for services, sources.
Eight variables are used as controls in the analysis.
Hospital Subsidiary: Because organizations that
are parts of larger organizations can benefit from resource
exchanges with the parent organization, this variable was
used as a control. A cushion of resources could have a
positive effect on innovative activity (Cyert and March,
1963). Therefore, if the treatment center is a part of a
hospital or located on a hospital campus, it is coded as 1,
54 JHHSA SUMMER 2014

while organizations that are not owned by hospitals or

located in hospitals are coded as 0.
Size: Because the size of an organization may
explain the absence or presence of innovative activity
(Baldridge and Burnham, 1975; Bantel and Jackson, 1989),
this variable is used as a control. Organization size was
measured by the number of full-time equivalent employees
the year before the on-site interview was conducted, and
was transformed by its logarithm.
Director Experience: Experience has been found
to have both positive and negative relationships with
innovation. The experience of the substance abuse center
director is measured as number of years in the field. Data
were gathered from responses to a query regarding the total
number of years the respondent worked in the substance
abuse treatment field, and was transformed by its
logarithm.
Opiate Treatment: Two of the medications have
been used for those who have addictions to opiates. To
control for the use of these medications for this purpose, we
created a dummy variable coding “1” for centers that treat
clients with opiate addictions and “0” for centers that do
not treat clients with opiate addictions.
Dual Diagnosis Treatment: Clients diagnosed
with an addiction to alcohol or drugs and depression can be
treated with Selective Serotonin Reuptake Inhibitors
(SSRIs). To control for the use of this medication for this
specific purpose, we created a dummy variable coding “1”
for centers that handle patients with dual diagnoses and “0”
for centers that do not treat patients with dual diagnoses.
Physician Staff/Contract: To control for access to
prescriptions for medications being an explanation for
greater use of MATs, we created a dummy variable coding
“1” for centers with availability of a staff or contract
physician, and “0” for those centers that do not have access
to prescribing professionals.
JHHSA SUMMER 2014 55

Ownership: To control for ownership being an

explanation for greater use of MAT, we created two
dummy variables. Government-owned centers are coded
“1”and “0” is coded for those that have other ownership.
Centers operating for profit were coded “1” and others “0”.
The residual, comparison, category is that of organizations
that are non-profit organizations.

ANALYSIS AND RESULTS

Descriptive statistics of the data tell us that the

average leader of a SUD treatment center in the data set has
obtained either a Bachelor’s or Master’s degree (analyzed
prior to creating the education category variables) and has
worked in the healthcare field for 19 years. He or she has a
staff of approximately 34 full time employees and at the
time of the interview averages one technological innovation
or MAT adoption out of a possible four queried (see Table
1). Among the predictor and outcome variables, correlation
analysis indicates significant positive correlations between
leaders having clinical degrees and adoption of MAT.
There is also a positive and significant correlation between
the proportion of revenues from sources of payments for
treatment of specific individuals and MAT innovation
adoption at the organizational level.
Ordinal regression, using the Polytomous Universal
Model (PLUM), with a link Negative Log-Log, was
utilized to analyze the data and test the hypotheses. Table
2, column 1, shows that having a clinical degree is
significantly related to MAT with a regression estimate of
.502 and standard error of .12, p< .01. Therefore,
Hypothesis 1 is supported.
 M SD 1 2 3 4 5 6 7 8 9 10
56

1. #MATs 1.00 1.08 1

2. Hospital .21 .41 .27 1
3. Size (lg) 2.83 1.16 .22 .04 1
4. Director 2.83 .54 .15 .05 .10 1
TABLE 1

Experienc
e BHC(lg)
5. Physician .79 .41 .19 .04 .30 .01 1
Staff/
Contract
6. Opiate .88 .33 .15 .09 .15 .01 .16 1
Treatment
7. Dual .74 .44 .20 .08 .14 .00 .16 .04 1
Diagnosis
Treatment
8. Governme .14 .34 -.03 -.10 .10 .05 .10 .10 .00 1
nt-Owned
9. For-Profit .15 .36 .07 -.03 -.10 -.01 -.10 -.05 -.03 -.15 1

N=555 r>.09<.11=p<.05; r>.11=p<.01

Clinical .48 .50 .19 .02 .10 .17 .07 -.03 .10 .07 -.04 1
Degree
Proportion .54 .39 .32 .17 .11 .05 .09 -.05 .08 -.12 .01 .02
Private
Funds:
Fees for
Individual
Means, Standard Deviations and Correlations
JHHSA SUMMER 2014
JHHSA SUMMER 2014 57

The analysis described in Table 2, column 1, also

shows that there is a significant and positive relationship
between private benefit funding and adoption of MAT with
an ordered logistic regression coefficient estimate of 1.103
and a standard error of .21, p < .01. When analyzing the
relationship between specific private benefit sources of
funding and adoption of MAT, we found that private or
commercial insurance, Medicaid, Medicare, and Health
Maintenance Organization (HMO) funds for specific
individuals, and client payments had positive and
significant associations with MAT adoption (column 2).
There was a converse negative and significant relationship
between centers receiving higher percentages from public
funds and the extent of adoption of medications, with the
analysis of the specific sources of funds coming from the
public criminal justice system, federal block grants, and
federal, state and county funds (column 3) all negatively
related to MAT adoption. However, when specific sources
of public funds were analyzed along with specific sources
of private benefit, funds from the criminal justice system
were negatively and significantly related to innovation
adoption (column 4), while the remaining sources of public
funding were not significant. The private and commercial
insurance, Medicare and HMO funding remained positively
associated with MAT adoption at the organizational level.
Therefore, Hypothesis 2 is supported.
58 JHHSA SUMMER 2014

TABLE 2
Ordinal Regression-Polytomous Universal Model (PLUM): Link
FunctionNegative Log-Log. DependentVariable=Index Count
(0-4) Medication-Assisted Treatment (MAT)
!! Col 1 Col 2 Col 3 Col 4

Control Variables Estimate Estimate Estimate Estimate

Size 239** .249** .233** .251**
Hospital 0.273 0.05 0.26 0.032
Director Tenure BHC .270* .285* 0.206 0.237
Opiate Treatment 417* 0.284 .486* 0.325
Dual Diagnosis Treatment .544** .546** .404* .530**
Physician Staff/Contract .419* .347** 0.181 0.327
Government-Owned 0.341 .382* 0.198 0.196
For-Profit 0.026 0.198 -0.025 0.216
Independent Variables
Clinical Degree !
.502** !
.415** !
.538** .406**
Proportion Private Funds:
Fees for Service !
1.103** !
--- !
--- !
---
Components of Private Funds
Private Insurance ! !
1.945** ! !
2.190**
Medicaid ! .655* ! 0.851
Medicare ! 1.683** ! 1.874*
HMO ! 1.973** ! 2.194**
Client Pay ! .693* 1.064
Components of Public Funds ! !

Criminal Justice ! ! !
-3.936** !
-2.254*
Federal Block ! ! - .681* 0.707
Federal Funds ! ! -1.377** -0.041
State ! ! -.751* 0.673
County ! ! -1.652** -0.288
Cox Snell Pseudo R-sq !
0.26 !
0.3 0.29 0.32
19.8 12.89 17.31 12.89
Hosmer-Lemeshow GOF
!
(p=.71) (p=.97) (p=.84) (p=.97)
*p<.05 **p>.05<.01!
JHHSA SUMMER 2014 59

DISCUSSION

A convergence of data across the for-profit, not-for-

profit and government sectors (Gowdy, Hildebrand,
LaPiana & Campos, 2009: Young, Salamon & Grinsfelder,
2012) is evident in that ownership is not significantly
related to adoption of MAT innovations in SUD treatment
centers. It is the source of funding and not the legal form
of organizational ownership that appears to make a
difference. Further, analyses disaggregated by type of
education show that each clinically relevant education
category is significantly different from the omitted
categories of BA/BS Degrees or less and advanced degrees
in a non-clinical discipline.
In addition, sensitivity analyses were performed
using logistic regression analysis for each type of MAT as a
dependent variable. The results show the same pattern of
relationships for clinical education and public funding for
each of the adoption of SSRIs, Naltrexone and Disulfiram.
They are more likely to be adopted in SUD treatment
centers that have executive directors with clinically
relevant educational socialization, and more likely to be
adopted in SUD treatment centers that have higher
proportions of their funding coming from private market
based (fees for service) benefit sources. The relationship
for the adoption of Buprenorphrine, the newest evidence
based MAT with the lowest base rate of adoption at the
time of the data collection, differs from the other three.
Buprenorphine reaches statistical significance with
clinically relevant education, but its relationship with
adoption is not explained by funding source or by type of
ownership. As with the multinomial regression models that
tested our hypotheses, the Hosmer-Lemeshow goodness-of-
fit statistics for each of the binary logistic regressions
support our models.
60 JHHSA SUMMER 2014

This analysis was designed to test hypotheses

concerning the extensiveness of MAT adoption in a social
entrepreneurship context, proposing that extensiveness of
innovation is affected by the fit between the socialization of
leadership and the innovation, as well as by the fit between
environmental contingencies (such as funding source) and
MAT.
This study examined the professional socialization
of leaders of SUD treatment centers by focusing on the
relevance of formal education and its relationship to a
proclivity to adopt MAT for patients. We proposed a
hypothesis that posited positive relationships between the
observable characteristics of SUD treatment center leaders
and adoption, at the organizational level, of MAT
innovations. While these characteristics serve as proxies
for values derived during socialization processes,
professional identity and social relations, these assumptions
are supported by social categorization theory where identity
construction is an outcome of cognitive processes (Oakes,
Haslam & Turner, 1994).
For Hypothesis 1, our analysis shows that obtaining
a clinical degree is significantly and positively related to
the organizational level decision to adopt medications.
Those organizations where leaders received treatment-
relevant professional education and socialization were more
likely to utilize MAT. Thus, those organizational leaders
who experience these types of professional socialization
may be more able to recognize the value of maximizing
evidence based treatments for their clients, thereby more
easily implementing institutionally contested
pharmaceutical treatment into SUD treatment protocols.
The complexity of the terrain is demonstrated by the non-
exclusive reasons provided by the non-adopters of a
particular MAT: 64% of those who do not use
Disulfiram/Antabuse claim that it is inconsistent with their
center’s philosophy, and 27% of them claim they do not
JHHSA SUMMER 2014 61

use it because of its cost. For Buprenorphrine, the

comparative percentages are 47% and 25%, for Naltrexone,
50% and 33%, and for SSRIs, 41% and 21%. Because
pharmaceutical treatment can be expensive and is not
necessarily reimbursed by insurers, adoption can result in
treating fewer clients with available resources than
traditional behavioral treatments, or treating patients
differentially based on access to individualized payments.
However, it could be a paradigm shift in treatment
effectiveness for some clients. This is likely to be
especially true in fields like SUD treatment where
behavioral change is very difficult to sustain and relapse is
a prominent concern.
It is also important to note that advanced degrees in
business or other disciplines without formal socialization in
a counseling discipline were not statistically significant
predictors of decisions reflective of adoption of MAT,
suggesting the importance of the content of professional
experiences and the values such content can impart. Thus,
it appears that the disciplinary area of study, rather than the
level of education, is associated with social capital that
drive our results. The support for Hypotheses 1 is evidence
that values inherent in socialization experiences of these
leaders of SUD treatment organizations can predict
managerially strategic adjustments, including the risky
organizational level decision-making behavior concerning
the adoption of institutionally contested medications.
These results are consistent with the proposition that
alignment between organizational characteristics such as
leader socialization and the innovation itself can lead to
more extensive diffusion of innovation (Ansari, et al. 2010)
as well as the links between learning and identity which are
built through participation and social contact in
communities of professional practice (Ferlie, Fitzgerald,
Wood & Hawkins, 2005). The fidelity of these adoptions
and the extensiveness of these may change over time, as the
62 JHHSA SUMMER 2014

institutional arena becomes less contested, but social and

cognitive barriers that mutually reinforce each other would
have to be overcome through social interaction, trust and
motivation.
Hypothesis 2 posits that the adoption of innovative
medications will be more likely in organizations where a
funding model based on fees for service to individuals is
more prevalent relative to other sources. The significant
and positive relationship found between the proportion of
private source funds received by SUD treatment centers
and adoption of medications is also evidence for support of
Murphy and Coombes’ (2009) argument that the values of
the environmental context are important considerations in
the process of social sector opportunity discovery when it
includes the decision to act upon the opportunity. MAT
availability appears to be associated with funding sources
that represent public, private and mixed benefits.
This finding could explain why more centers have
not acted upon the opportunity to adopt evidence based
MAT. It may well be that in organizations where higher
portions of funding derive from public sources the value of
medications is perceived differently from those receiving
greater portions from private benefit, fees for service,
funding. While public goods benefit everyone and are
funded by public monies, private goods are consumable
and are funded through private sources and may be
perceived to benefit only members of a specific group
(Kingma, 1997). Also, this finding supports the theory that
there is a relationship between the type of services provided
and type of revenue stream (Fischer, Wilsker & Young,
2010), with “private” services such as the provision of
individual medications to clients being more positively
related to the private benefit proportion of funding than to
the public proportion. Furthermore, the apparent lack of fit
between centers with higher proportions of public funding
JHHSA SUMMER 2014 63

sources and MAT supports the proposition that lack of fit is

related to low innovation diffusion (Ansari, et al. 2010).
It is important to notice the consistent negative
relationship of adoption with funding from criminal justice
sources across the several equations. The finding of a
negative association with this source of funding is not
novel. Data from an older national sample of SUD
treatment programs reported reliance on criminal justice
referrals to be negatively associated with availability of
psychotropic medications (Knudsen, Ducharme & Roman,
2007) in SUD treatment programs. Medication use in SUD
treatment is relatively low within services delivered as part
of services provided within correctional institutions (Smith-
Rohrberg, Bruce, & Altice, 2004; Rich, Boutwell, Shield et
al., 2005) as well as in treatments that are associated with
criminal justice referrals. Kubiak, Arfken, and Gibson
(2009) found that less than one-third of Departments of
Corrections’ administrators reported that medications are
provided to offenders receiving community-based SUD
treatment services.
Here an explanation may rest on a collision of
different paradigms, those governing the delivery of
criminal justice and those governing the delivery of
medical care. While many professionals and other actors in
the criminal justice system have become convinced of the
value of “diversion” to treatment as an alternative to
imprisonment for non-violent offenders, it is likely that this
support is within the context of their guiding paradigm.
Specifically, the traditional SUD treatment centered on 12-
step philosophy has long been attractive to many in the
criminal justice community, likely because it rests upon
self-investment, self-denial, conformity to a strict set of
rules, and passage through a clearly described set of
numbered “steps.” This contrasts with the image of passive
and perhaps even indulgent treatment of the patient through
the administration of medications to curb his/her desires or
64 JHHSA SUMMER 2014

“craving” for the use of psychoactive substances. This

inconsistency may explain the distinctive diminution of
adoption of MAT by SUD treatment programs that receive
greater portions of their funding from criminal justice
sources.
The results also demonstrate that the form of
organizational ownership is not a predictor of MAT
adoption - an indicator of convergence across sectors, when
resource funding is considered. There appears to be
variation within different types of ownership or
organizational forms. As suggested by Bozeman and
Straussman (1983: p 86), it appears that innovation can be
easily stifled when effectiveness is sacrificed to narrower
efficiency norms. When funding is unpredictable and
inadequate for meeting the demand for services, early
adoption is more risky and less likely. In resource
constrained contexts, efficiency of traditional treatment
methods that allow for treatment of larger numbers of
people, perhaps less effectively, may be preferred.
However, effectiveness is subordinated to efficiency goals,
a lack of adoption of evidence based treatments could be
dysfunctional for both the organization and those served.
The control that is perceived to be exerted by funding
sources can influence resource strategies and appears to be
a better predictor of the adoption of novel treatment
combinations in SUD treatment centers than the legal
ownership status of the organizations.

Limitations
This study has several limitations. One limitation
of this study is missing data. Because of missing data on
some variables, cases were eliminated from analysis
through list wise case deletion. However, given the large
number of centers sampled, there were enough cases to
have adequate power for this study. Also, logistic
regression analysis of whether a case was observed or
JHHSA SUMMER 2014 65

missing was not predicted by the linear combination of

independent and control variables included in our analyses,
suggesting that the cases that are missing at random are not
biasing our results (Goodman and Blum, 1996).
Since the sample was drawn from a population of
community treatment programs where all members of the
community are eligible for services, the findings are limited
in their generalizability beyond these parameters.
Importantly the SUD treatment programs that are part of
the Department of Veterans Administration are not
included in the sampling frame. These organizations have
very different treatment and policy environments than the
community based treatment organizations in our sample,
our inability to include these organizations in our analyses
may affect the generalizability of our findings and could
therefore be considered a limitation.
We used education level and field of study as an
indicator of formal socialization. Educational socialization
is a process through which professional identity, an aspect
of personal and social identity that develops in professional
personnel as a result of their work activities, and social
capital, productive benefits derived from social relations,
emerge. While the operationalization is consistent with
social categorization theory (Oakes, Haslam & Turner,
1994), and the processes documented to be associated with
identity development (Pratt, Rockmann & Kaumann,
2006), more direct measures of the variation in professional
identity and social capital can be used in future studies to
provide more nuanced understanding of their impact on
decision making, adoption of new practices, and
organizational adaptation.
The data for this analysis were collected before
parity legislation for behavioral health with physical health
care was implemented. It is beyond the scope of our
analysis to consider the variation across states in parity
legislation or the potential effects of The Affordable Care
66 JHHSA SUMMER 2014

Act. However, based on the experience of Massachusetts,

which implemented its own universal insurance coverage in
2007 incorporating substance abuse services into benefits
to be provided to all residents, coverage alone is
insufficient to increase treatment use (Capoccia, Grazier,
Toal, Ford II, & Gustason, 2012).

Implications
These findings contribute to the literature by
offering evidence for the importance of identifying the
environmental context of social purpose organizations to
help explain organizational decisions concerning the
adoption of innovations that challenge a prevailing
ideology. It also suggests the importance of the
socialization of leaders of SUD enterprises whose
educational experiences are related to whether their social
enterprises act upon opportunities to address social needs
through adoption of ideologically contested MAT. In
addition, MAT adoption in the resource constrained
environments of SUD treatment organizations appear to be
more limited in organizational contexts with greater
dependence on public funding sources as compared to those
who have larger portions of their revenues derived from
commercial (fees for service) sources. It appears that
centers that depend more on public block sources of
funding, rather than fees for services for individuals, avoid,
consciously or unconsciously, risky behaviors, thus
reducing the adoption of innovations that can change
treatment paradigms and effectiveness. These findings
support propositions that sources of income for social
mission-oriented organizations tend to be aligned with the
perceived nature of benefits provided to clients (Young,
2007). That is, sources of private (fees for services)
funding are more aligned with benefits for individuals and
sources of public funding are more aligned with collective
type of benefits. These findings can also assist government
JHHSA SUMMER 2014 67

and policy making organizations to address the social and

economic factors that influence the adoption of innovations
across SUD treatment organizations across other social
mission sectors. The competitive and legitimacy challenges
faced by treatment centers, in addition to the fiscal changes
on the horizon, create uncertainty and the imperative for
adaptation. While treatment organizations appear to be
responding to market pressures, there appears to be
patterned differences among organizations (Young,
Salamon & Grinsfelder, 2012) in their adoption of MATs.
Uncovering patterns across organizations can help identify
the risks and opportunities in the diverse health care sector
with its many subfields or specialty organizations. Even
when there is legislation for universal coverage, variation
will likely exist among treatment organizations that will
need to be understood to effectively serve behavioral health
care needs.
68 JHHSA SUMMER 2014

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