Many of the specific regulations in this proposal seem specifically designed to force existing opioid maintenance treatment programs out of business and to inhibit the ability of new programs offering new services to open. This is occurring in light of an ever increasing overdose epidemic, in which Virginia is seeing overdose rates above the national average. As most other regulatory authorities are begging treatment providers to find ways to reduce barriers to care, get more patients into treatment, and retain them, these regulations seem particular restrictive in preventing allowing programs to do just that.  Specifically:

12VAC35-109-40; 12VAC35-109-50: Regarding increased screening questions for patients.   Anytime that a patient calls interested in obtaining treatment a treatment program should be open to seeing that patient and evaluating them for possible admission. Additional screening questions before a patient can even be considered for admission serve no purpose other than to set up an additional barrier to treatment. A full evaluation of the patient will always be done before it is decided if the patient is appropriate for admission and treatment. There seems to be no purpose to mandate additional screening of patients, beyond questions such as “Are you using opiates and are you looking for help?” before providing them an opportunity for a full and comprehensive evaluation.

12VAC35-109-200: Staffing qualification requirements. While enhanced staffing training and certifications would always be desirable it is just not reasonable to require additional staffing restrictions during a time when there are marked staffing shortages everywhere. These regulations will have a significant effect on the ability of many treatment programs to operate. There are simply not enough board certified addition physicians, or even physicians well trained in addiction medicine to fill the required positions. As the nation faces a national physician shortage there are virtually no places where a physician can learn about addiction treatment, particularly about addiction treatment with methadone, outside of the OMT environment. Training on the job is the rule. Furthermore, to allow this necessary training on the job there must be the ability to allow other more appropriately trained and certified physicians to leverage their skills to multiple locations that require them. This will entail the ability to supervise multiple mid-level providers as well as other physicians that may not be well trained in addiction medicine. All of this supervision can be done remotely with currently available technology and EMR systems. An arbitrary requirement of onsite time per patient enrolled in the program makes no sense. Well trained physician time must be maximized and efficiently utilized. Travelling to multiple locations to meet an onsite time requirement is not an efficient use of this scarce resource.

The same work force situation exists with the proposed requirements for RNs as opposed to LPNs and the minimum counselor certifications and maximum counselor to patient restrictions. Many OTPs will simply not be able to find an adequate number of personnel to fill the needed positions.

There are multiple other proposed requirements in this draft document that are just not able to be done, or are extremely impractical to implement, due to staffing, facility, funding, time, and other limitations. Implementation of these regulations as proposed will result in a marked decrease in the amount of opioid maintenance treatment available to the citizens of Virginia and a subsequent increase in the number of opioid overdoses in addition to increases in other morbidity and mortality secondary to inadequately treated opiate use disorders. I would urge significant reconsideration of many of these proposals with more input from those on the ground who are diligently working to provide care to the most number of patients in the most efficient way possible.

Please also consider the very detailed comments previously posted by David Cassise, the President of VAMARP.  

The implementation of these proposals, unchanged, will significantly impair the ability to provide opioid maintenance treatment in the state of Virginia. These proposals set up multiple significant barriers to treatment that are directly contrary to the national movement being lead by SAMHSA and ASAM trying to make addiction treatment more focused on harm reduction and available to the most number of people possible. 

Thank you for your attention to these serious matters. Please let me know if I can provide you with any additional information.