In response to the proposed changes, I am in agreement with the responses made by Dr. Tannenbaum and David Cassise.  I would like to elaborate specifically regarding to the counseling ratio proposals. As a licensed clinical social worker who practices privately in addition to serving as the Director of Clinical Services for ARS for many years, I have seen many barriers implemented through regulations across states that hinder OTP's ability to provide quality care and/or serve as a reason for citations.  As others have stated, it is without a doubt desirable to have counselors who are certified and/or licensed.  With a requirement of 63% certified counselors with a maximum caseload of 45 and the remainder of uncertified counselors with a maximum caseload of 30, this will only further provide barriers to care.  An important aspect of this is having regular supervision where as a licensed supervisor works closely with the counseling staff.  Whether someone is certified or not, will not necessarily dictate their ability to provide quality care to those we serve. 

In addition to the ratio's and credentials mentioned above, requiring a minimum of one hour counseling per week for the first 6 months, is unrealistic. In order to provide patient centered care, the counselors are trained to meet clients where they are. For some, this is an unrealistic expectation and does not equate success and may further push our pre-contemplative clients; clients suffering with mental illness; and clients with unresolved trauma from attending treatment altogether.  Best practices will dictate if clinically indicated a patient will have additional counseling which may equate to weekly or more.  For some, weekly counseling may not be clinically indicated. 

I am in agreement if a ratio is needed, a 60:1 ratio is realistic and provides counselors with plenty of time throughout the month to meet the needs of the individuals served.  I would be more than happy to provide additional information for this if requested.