Medication Assisted Treatment for Opioid Use Disorders
2016-07-26 2016-04-17 2016-04-17 2016-04-17 2016-04-17 2016-04-17 2016-04-22 2016-04-17 2016-04-17 2016-04-17
SAMHSA-2016-0001-0511 SAMHSA-2016-0001-0012 SAMHSA-2016-0001-0015 SAMHSA-2016-0001-0022 SAMHSA-2016-0001-0024 SAMHSA-2016-0001-0035 SAMHSA-2016-0001-0098 SAMHSA-2016-0001-0009 SAMHSA-2016-0001-0013 SAMHSA-2016-0001-0028
04:00:00 04:00:00 04:00:00 04:00:00 04:00:00 04:00:00 04:00:00 04:00:00 04:00:00 04:00:00
https://api.regulations.gov/v4/comments/SAMHSA-2016-0001-0511 https://api.regulations.gov/v4/comments/SAMHSA-2016-0001-0012 https://api.regulations.gov/v4/comments/SAMHSA-2016-0001-0015 https://api.regulations.gov/v4/comments/SAMHSA-2016-0001-0022 https://api.regulations.gov/v4/comments/SAMHSA-2016-0001-0024 https://api.regulations.gov/v4/comments/SAMHSA-2016-0001-0035 https://api.regulations.gov/v4/comments/SAMHSA-2016-0001-0098 https://api.regulations.gov/v4/comments/SAMHSA-2016-0001-0009 https://api.regulations.gov/v4/comments/SAMHSA-2016-0001-0013 https://api.regulations.gov/v4/comments/SAMHSA-2016-0001-0028
G Lee Angie Charles Thomas James Rick Nancy Hallie Brianna
Thibault Tannenbaum Geren Atkins Grinley Murray Campana Rubio Marcotte Anonymous
I am a physician who has run an outpatient buprenorphine-naloxone treatment program for 5 years now, limited to a maximum of 100 patients at a time, so welcome the increased access proposed.  Since you are seeking comments primarily related to the reporting requirements for those that choose to treat up to 275 patients, one comment I have is that the burden of reporting has less to do with the questions being asked than with the reporting method.  If there is a 15 page paper form to complete each month, that would be burdensome. I would not consider it burdensome, though to complete a one page on-line form with blanks to fill in for: 1) Numbers of patients seen per month; 2) Number who are currently in or have completed outpatient drug counseling; 3) Number who have left the program and reason.Other comments:1)Part of your proposed rule is unmanageably vague:b. Percentage of active buprenorphine patients (patients in treatment as of reporting date) that received psychosocial or case management services (either by direct provision or by referral) in the past year due to:1. Treatment initiation2. Change in clinical status--What does psychosocial or case management service include?  If you mean group outpatient drug treatment or individual counseling, it should say that.--What does change in clinical status mean?--When you are looking for percentages, is there a certain benchmark we are being required to meet?2)Another part of your proposed rule is also vague and burdensome the way it is worded:c. Percentage of patients who had a prescription drug monitoring program query in the past month--We query the PDMP for every single controlled substance prescription, so I am not sure how writing 100% every month is going to help you.  If we were to accidentally miss someone, I am not sure how we would know it.  It would seem to me the PDMP for each state would have a better handle on that information.3)There should be some oversight of HOW patients are being treated with buprenorphine and none of this data gathering includes that.  The makers of Suboxone, for instance, recommend no more than two 8-2mg films daily as the usual maintenance dose, and that up to three a day can be given for extenuating circumstances, yet many doctors in New York City are well known for prescribing three a day consistently, for months, if not years, and giving 30 days of medication at a time. Most opioid addicts know they do not need three a day, so the extra medication is just a source of income to them.  Where is the oversight on that?4)One of the biggest burdens likely to keep some providers from wanting to see more than 100 patients is the prior authorizations required by most insurance companies (particularly all versions of Medicaid) prior to starting buprenorphine and, for some companies, quarterly.  Some will only pay for the generic buprenorphine pill, which is difficult to split in order to taper someone down over time, and will not pay for Suboxone or its competitors. Others will stop paying for buprenorphine altogether if someone tests positive on a urine drug screen for marijuana (which is not even treated with buprenorphine). Yet others have a 3 to 5 day wait for approval for a new patient we have just seen who has stopped the heroin and wants their buprenorphine that first day.  What are they supposed to do for 3-5 days, continue heroin?  The insurance companies need oversight as wellor at least we providers should have a 24 hour hotline phone number to call to have SAMHSA intervene with the insurance company. This is a good start but it does not go far enough. As an Addiction Specialist I am capable of providing significant services to a large number of patients. When I was a Family Practitioner I use to manage more than 5000 patients. There is no limit on the number of patients that any other type of specialist can treat. Endocrinologists are not limited in the amount of insulin dependent patients that they can treat. Addiction is a medical disease and it needs to be treated by medical specialists. I can treat more people and provide fantastic care. I can provide full time counseling services, 24 hour phone coverage, evening, weekend, and holiday coverage, integrated electronic medical records with real time following of prescriptions that patients are filling, etc. However, I cannot expand to provide these services if my ability to see patients is limited to only 200.  Please allow me to practice to my full potential and to be able to provide the services that patients need and are entitled to at a reasonable cost. I can only do this if I have the ability to increase the volume of my practice thus dispersing the cost of services across more patients. I would urge you to consider eliminating a treatment limit all together for appropriately certified physicians, or at the very least increasing to number permitted to be treated to a more significant 500 or 1000 patients. Note that Senate bill S.1455 (TREAT Act) was recently amended to allow a 500 patient limit. Perhaps this rule could be changed to be consistent with that initiative.    Persons suffering from Opioid Use Disorder have a difficult time finding treatment in the current system. Not only are Medication Assisted Treatment locations few and far between, they also have enormous waiting lists leaving those who want treatment, unable to secure it. The current limit of 100 patients per prescriber is not enough to handle the amount of persons affected. Please support increasing this limit to 200 and also continue to look into other ways we can make treatment easily accessible. Thanks so much for sending this out and furthering efforts to increase access to medication assisted treatment. I was a Suboxone prescriber for over seven years, though I currently work as a medical administrator for a multi-site mental health and substance abuse agency in CT. We do offer Suboxone in one of our outpatient clinics; this is a part of a program that includes Intensive Outpatient, relapse prevention, and much co-occurring behavioral health treatment.I am in total support of raising the limit from 100 to 200. I also think the added requirements for prescribers are reasonable, though I would want a crisp definition of what constitutes an acceptable setting. I am board certified but have never pursued additional certification from ASAM or in addiction medicine or psychiatry. I have however always prescribed in a clinic setting where counseling, at various levels of intensity, are provided. This also includes diversion strategies, lots of urine collection, and focus on treating co-occurring mental health problems, which are rampant in this population.As a final comment, where the need is greatest, is among the Medicaid population. Im hopeful that this increase in the limit will allow those few clinics that take Medicaid reimbursement, help meet this tremendous unmet need. With the shortage of prescribing physicians and the overwhelming opioid crisis, this would seem to be a rule change that is long overdue. I support the rule to change to the highest patient limit from 100 to 200 patients per qualified doctor.I am employed as a chemical health intake coordinator, a common call from an opiate user seeking help is frustration of trying to find an outpatient provider of bupronorphine thiat is accepting new patients. There is not enough providers to meet the needs of this community. Increasing the volume of allowed patients per provider will assist with opening more doors for this population to get they initial help they need so they can begin a recovery process.   I am a Board Certified Addiction Specialist and this bill is essential to helping the large numbers of opioid addicted patients who do not have access to MAT. Every patient who calls my office to get in my Suboxone program is asking for help and to save their lives. When I have to refuse treatment w Suboxone because of the current patient limit, I am depriving a life saving medication to a patient who may return to the street and overdose on heroin. PLEASE AT A MINIMUM RAISE THE CAP to 500 patients.Dr. Rick CampanaDiplomate ABAM, FASAM I am a board certified psychiatrist with added Qualifications in Addiction Medicine. I have treated patients suffering from addiction for over 25 years and have trained many future clinicians in this field.  Currently I treat United States veterans exclusively in a VA substance abuse program in the tri-state area of Kentucky, Ohio and West Virginia. This VA is one of two VA hospitals with highest percentage of prescription drug abuse.  We are trying to correct the poor prescribing practices of our predecessors.  Also the tri-state area tops the nation in drug overdoses. Unlike the private sector we cannot close admissions to our opiate treatment program to veterans suffering from opiate dependence when I reach my 100 limit.  We also cannot hire physicians willing to prescribe Suboxone to our veterans since they have lucrative private practices where they charge an average of $300 monthly just for their service (does not include cost of medication and $25 toxicology screen.) We cannot outsource these veterans to the private community because the government pays Medicare rates which are much lower than the $300/month.  The private doctors can easily  fill their 100 slots with folks willing to pay $300/month in cash.  I have not been able to convince my administration to apply for SAMSHA official OTP program with institutional license which would allow us to expand services. The same lack of knowledge in this area which lead to the problem seems to be impeding the solution.  So I am chronically frustrated and worry about welfare of our veteran population. Some of the pressure has been alleviated by outsourcing of patients to local methadone programs.  I applaud President Obamas push to expand training of pain management in medical schools.  I would favor increasing the limit to 200 for clinicians board certified in addiction and for VA hospital programs.  I do have some concerns about private clinicians with little experience in treating addiction profiting from those addicted to pain medications without providing appropriate care.  Increasing the number of prescriptions doctors can write for medication used to treat opioid addiction  is extremely good news. I just wish the door would open even more. The use of these medications has proven to be extremely effective.  I am at a loss as to why we are moving so slowly in changing our culture around drug treatment and am saddened by the amount of unnecessary deaths. I just hope that this MAT rule moves forward.  Thank you for your advocacy for doing the right thing!  As someone who works with the addiction community and sees the impact of the shortage of providers able to prescribe suboxone and take on new patients, I fully support expanding the ability of these much needed providers to take on additional patients. This is a small step to start helping reduce the amount of heroin/opiate overdose deaths that are so prevalent in our community due to the lack of help/assistance with people suffering from addiction who are unable to find the help they need. 