My comment may pertain to several sections of this regulation or others, perhaps mostly to 12VAC35-105-580 Service description requirements and 12VAC35-105-940 Criteria for involuntary termination from treatment.

I believe that current regulations contributed, either intentionally or unintentionally, to the counterproductive and punitive discharge of my loved one from a respected outpatient treatment program in which he had made progress. The discharge resulted in a tailspin and subsequent hospitalizations for detox that might have been avoided had he been allowed to continue the outpatient treatment.

Briefly, after five months of sobriety this year and gradually reduced outpatient treatment plans, my loved one had a relapse and unsuccessful suicide attempt that resulted in an emergency room visit and overnight hospitalization. Unfortunately, this resulted in his discharge from the outpatient treatment. The clinical director told me that Virginia state regulations for treatment centers require them to follow ASAM protocol, and that the protocol required them to recommend the highest level of care (residential rehab) for someone who attempts suicide and is hospitalized. Since the treatment program does not offer inpatient rehab, they said they could no longer treat him and recommended some residential programs. My loved one was understandably unwilling to go back to residential rehab (having three previous stays), and so was left with no professional care or therapy. Upon checking with some other Northern Virginia outpatient programs, one said it would accept him at a PHP level, requiring attendance five days a week for most of the day. This, too, was something he was unwilling to do, given that he had returned to work after a five-month leave of absence, feared losing his job and thus his insurance, and did not want to incur further increased treatment costs.

My loved one had voluntarily informed his outpatient program of his suicide attempt and hospitalization, recognizing that it should know about it for his treatment, and expecting that it might alter his treatment plan, such as returning to more meetings and a higher level of outpatient care. Never did he or we expect that it would result in his being discharged with an insistence that he go to residential treatment. While the intentions of relevant ASAM protocols and Virginia state regulations are good, the effect is punitive and counterproductive. Surely it would have been better for my loved one’s mental health and recovery if he could have continued outpatient treatment at his current or another program at a level that permitted him to continue working. Instead, he was left in limbo with no access to any outpatient care.

In seeking to better understand these professional protocols and regulatory requirements, I corresponded with Leigh Hause-Alvarado, Director of Quality Improvement at the American Society of Addiction Medicine. She informed me: “While we cannot weigh in on the clinical care or legal proceedings of an individual patient, one of the core principles of The ASAM Criteria is individualized, person centered care. The ASAM Criteria speak at length about the patient’s role in working with their clinicians to develop their treatment plan. While the Criteria help to identify the least intensive level of care where a patient can safely be treated, they also note that the level of care placement can differ from what is recommended based on the patient’s preferences. In addition, the standards incorporate the use of motivational strategies to work with the patient to encourage greater participation in treatment. The ASAM Criteria does not recommend discharge for patients who are not willing to enter a more intensive level of care.”

I relayed this response to VDBHDS and received this reply from Susan Puglisi, Esq., Regulatory Research Specialist, Office of Regulatory Affairs: “The ASAM provisions of the licensing regulations do not specifically require discharge. However, 12VAC35-105-580 requires a provider to develop and implement a service description which include service termination and discharge criteria. It is likely that your [loved one] met these criteria, although I cannot say for certain without seeing their service description.  [The provider] is required to discharge individuals that meet their termination and discharge criteria, not doing so would be a violation of regulation.”

I appreciate that there need to be protocols to guide professionals’ treatment plans, but providers’ recommendations have to be feasible, affordable and something a patient will willingly do. I believe VDBHDS regulations should clarify that providers have the flexibility to allow patients to continue outpatient treatment under circumstances similar to what I described, e.g., with one relapse after five months.