Exhibit 4.

Outpatient substance use treatment facilities that did and did not offer medication treatment (MT) in 2016, by state characteristics

State characteristic	Facilities offering MT		Odds ratios, comparison of facilities offering and not offering MT
	Numbera	Percent	Unadjusted	Adjustedb
12-month prevalence of heroin use, 2015–16c
Low (<0.37%; n = 5,666)	1,790	31.6	1.00	1.00
High (≥0.37%; n = 6,027)	2,428	40.3	1.46****	1.67***
Opioid overdose death rate per 100,000 in 2015–16d
Low (<13.1; n = 5,729)	1,716	30.0	1.00	1.00
High (≥13.1; n = 5,964)	2,502	42.0	1.69****	2.25****
Expanded eligibility for Medicaid (all facilities)
No (n = 4,118)	1,371	33.3	1.00	1.00
Yes (n = 7,575)	2,847	37.6	1.21****	1.31
Expanded eligibility for Medicaid (facilities accepting Medicaid)
No (n = 2,608)	713	27.3	1.00	1.00
Yes (n = 5,053)	2,165	42.8	1.89***	1.81***
Number of MT medications covered by state’s Medicaid programe (all facilities)
One (n = 703)	174	24.8	1.00	1.00
Two (n = 1,818)	559	30.7	1.35***	1.68
All three (n = 9,172)	3,485	38.0	1.86****	2.32*
Test of trendf	—g	—g	1.44**	1.44**
Number of MT medications covered by state’s Medicaid programe (facilities accepting Medicaid)
One (n = 342)	102	29.8	1.00	1.00
Two (n = 1,232)	323	26.2	1.34	1.31
All three (n = 6,087)	2,453	40.3	2.11	2.16
Test of trendf	—g	—g	1.52**	1.57**
All ASAM levels of care covered under state’s Medicaid program (all facilities)?h
No (n = 4,587)	1,543	33.6	1.00	1.00
Yes (n = 7,106)	2,675	37.6	1.19	1.22
All ASAM levels of care covered under state’s Medicaid program (facilities accepting Medicaid)?h
No (n = 2,950)	958	32.5	1.00	1.00
Yes (n = 4,711)	1,920	40.8	1.33	1.33

source Authors’ analysis of data for 2016 from the National Survey of Substance Abuse Treatment Services and other sources listed below.

notes Facilities that treated only patients convicted of driving while intoxicated or driving under the influence were excluded. Of the 11,693 facilities in the study, 4,218 (36.1 percent) offered MT (defined as offering methadone, buprenorphine, or extended-release naltrexone). ASAM is American Society of Addiction Medicine.

^aActual number of facilities, not imputed data.

^bAdjusted as explained in the notes to exhibit 1.

^cBased on data from Substance Abuse and Mental Health Services Administration. 2015–2016 National Survey on Drug Use and Health (see note 32 in text).

^dBased on data from Centers for Disease Control and Prevention drawn by authors from the CDC Wonder database (see note 33 in text).

^eBased on data from Henry J. Kaiser Family Foundation. Medicaid’s role in addressing the opioid epidemic (see note 35 in text).

^fTrend was tested by entering the continuous variable of the number of medications covered under Medicaid (one, two, or all three) into the logistic regression models. The odds ratios associated with this variable represent changes in the odds of outcome for each additional medication covered.

^gNot applicable.

^hBased on data for 2013 from the National Drug Abuse Treatment System Survey reported in Grogan CM, et al. Survey highlights differences (see note 36 in text).

^*p < 0:1

^**p < 0:05

^***p < 0:01

^****p < 0:001