Bagby, Tammy (LARA)  
From:  
Sent:  
To:  
Moreno, Jessica L <Jessica.Moreno@beaumont.org>  
Wednesday, August 24, 2022 1:30 PM  
LARA-BCHS-Training  
Subject:  
Comments on LARA Draft Rules for Substance Use Disorder Service Programs  
CAUTION: This is an External email. Please send suspicious emails to abuse@michigan.gov  
Good Afternoon,  
My name is Jessica Moreno and I am a Psychiatric Clinical Pharmacy Specialist with Beaumont Health. I have been  
working in mental health and substance use disorder for the past 8 years. I was glad to see that there will be an update  
to LARA’s rules for substance use disorders service programs and I would like to provide several comments in hopes of  
further improving the current draft.  
1. Overall, the document continues use of the term “medication-assisted treatment;” however, this term is now  
considered outdated and stigmatizing. Medications for addiction treatment are life-saving interventions; they do  
not “assist” in addiction treatment, they ARE addiction treatment. An alternative that still permits use of the  
acronym “MAT” would be “medications for addiction treatment.”  
2. I strongly support striking Rule 325.1303(3)(c) as until now, this rule has served as a significant barrier to  
evidence-based addiction treatment.  
3. I strongly support the authorization of mobile and branch units to expand access to treatment (Rule 325.1304);  
however, it is not clear why a branch would be limited to being open only 20 hours per week (Rule  
325.1304(4)(b)) or why it must be within 75 miles of the parent location (Rule 325.1304(4)(d)). These additional  
limitations simply limit access to treatment. Michigan has an extreme shortage of SUD treatment providers  
outside of urban areas so branch units should be permitted to operate to meet the needs of their localities.  
4. It is excellent that treatment facilities will be required to discuss potential benefits and risks of all treatment  
options available (Rule 325.1331(2)(d)); however, I strongly encourage LARA and/or MDHHS to compose a  
standard informed consent document covering this information so we can be sure that treatment programs are  
communicating consistent and truthful information to potential recipients.  
5. I strongly support the discouragement of discharge solely for return to use (Rule 325.1331(2)(e)). Changing this  
practice should significantly lower the risk of poor health outcomes and death for people who use drugs.  
6. I strongly support requiring programs to offer naloxone to their recipients (Rule 325.1331(2)(f)) as this is a  
solution that should be very easy to implement and will lower risk of death from overdose.  
7. I am glad to see the prioritization of evidence-based services for residential programs (Rule 325.1385(8)), though  
I recommend including guidance on what specifically those services are. Many treatment programs say they  
provide evidence-based care and then do nothing of the sort.  
8. I do not support the permission of “clinically managed withdrawal management services” as they are defined in  
Rule 325.1388(2) as there is no place in evidence-based withdrawal management for not permitting any  
medication treatment (current draft states “shall offer peer and social support services only”). Substance  
withdrawal can be extremely dangerous and deadly and should only ever be managed under the supervision of  
qualified clinicians in medical settings with the capacity to manage medical emergencies. The criteria listed  
under Rule 325.1388(5)(a) are too narrow in scope and still permit significant risk to recipients who fall outside  
of these criteria.  
Thank you for your time,  
- - - -  
1
August 30, 2022  
Tammy Bagby  
Licensing and Regulatory Affairs  
611 West Ottawa Street  
Lansing, MI 48909  
RE: Proposed Rule Set 2021-90 LR Substance Use Disorder Service Programs  
Dear Ms. Bagby:  
On behalf of Michigan hospitals, the Michigan Health & Hospital Association (MHA) appreciates the  
opportunity to provide comments on the proposed rule set 2021-90 LR Substance Use Disorder (SUD)  
Service Programs.  
The MHA supports updating the methadone treatment program rules to adhere to federal standards,  
which will reduce the required drug tests from 18 to 9 during year one treatment and 12 to 8 drug tests for  
year 2. The MHA supports the proposed removal of the requirement that currently limits prescribing  
buprenorphine or naltrexone to 100 individuals at a single time for medication assisted treatment. We also  
support the exclusion of these programs from the proposed rule which, as proposed, would only regulate  
methadone programs. These changes will improve patient care access by aligning state and federal  
standards and deregulating medication access of buprenorphine and naltrexone.  
The MHA supports the addition of limited certified counselors to provide outpatient counseling services to  
patients receiving SUD services and requests the department continuously evaluate R 325.1381 (6), the  
1 to 32 limited certified counselor-to-recipient ratio to ensure patient access isn’t being unnecessarily  
restricted. The MHA requests the department analyze the Wisconsin SUD 1 to 50 limited certified  
counselor-to-recipient ratio and evaluate if a similar model would benefit Michigan patient access  
for SUD programs.  
The MHA supports the addition of mobile units to expand patient access and requests clarification on  
limiting the number of branch offices and mobile units to 3. The MHA requests the department  
reevaluate limiting branch and/or mobile units if a parent organization has the staffing, resources,  
and community demand to provide more than 3 branch and/or mobile units.  
Please contact me at rsmiddy@mha.org if you have any questions regarding these comments or if you  
need additional information.  
Sincerely,  
Renée Smiddy  
Sr. Director, Policy  
Jessica L. Moreno, PharmD, BCPP  
She/Her/Hers  
Psychiatric Clinical Pharmacy Specialist  
Integrated Behavioral Health  
Beaumont Medical Group  
Cell: (248) 497-1690  
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2
THE PROVIDER ALLIANCE  
4507 SOUTH GRAND AVE, LANSING, MI 48933  
TO:  
Larry Horvath, Bureau of Community and Health Systems,  
Department of Licensing and Regulatory Affairs  
DATE: August 31, 2021  
The SUD agencies within the Provider Alliance express their gratitude to LARA for the dialogue  
during the last several years in an extended review of the Administrative Rules. There are  
many progressive additions and deregulations that we are very supportive of, and appreciate  
the work that has gone into these. This includes items like the addition of branch offices and  
mobile units, simplifying the rules around Medication Assisted Treatment, and the return of  
clinically managed (social detox) withdrawal management programs.  
During this season of public comment for the proposed rule changes, there are a few items that  
we would still request your attention to:  
R 325.1301 Definitions.  
(f) “Community change, alternatives, information, and training” or “CAIT” means prevention  
services offered by a substance use disorder services program.  
COMMENT: (f) We continue to express the concern that removing a licensing  
requirement opens up our communities to agencies that do not use trained professionals  
or evidence-based programming.  
(u) “Limited certified counselor” means an individual who is employed or who  
volunteers to work providing counseling to recipients in a substance use disorder  
services program licensed by the department under part 62 of the public health code,  
MCL 333.6230 to 333.6251, and who has completed a minimum set of state-approved  
requirements before completing the necessary prerequisites to become a certified  
alcohol and drug counselor by an organization approved or recognized by the  
department.  
COMMENT – (u) What are the state approved requirements?  
(w) “Methadone program” means a program engaged in opioid treatment of an  
individual with an opioid agonist treatment medication registered under 21 USC  
823(g)(1), methadone.  
COMMENT - (w) Suggest referring to a program as an Opioid Treatment Program. This  
is the national recognition for a program that provides methadone. A provider cannot  
utilize methadone without obtaining federal certification called Opioid Treatment  
Program. Referring to a program as a “Methadone Program” is archaic and contributes  
to unnecessary stigma associated with the term methadone.  
R 325.1309 Waiver from licensure survey.  
An Affiliate Member Organization of the Community Mental Health Association of Michigan  
THE PROVIDER ALLIANCE  
4507 SOUTH GRAND AVE, LANSING, MI 48933  
(1) The department shall provide and make publicly available a procedure for when a  
licensee may be eligible for a waiver from a licensure survey. The procedure must include  
maintaining a list of approved accrediting bodies for programs.  
(2) On or before October 1 of each year, the department shall publish a list of programs to  
receive a licensure survey in the next calendar year.  
(3) An eligible licensee may request a waiver from licensure survey on or before November  
1 of each year. A waiver request shall be submitted on a form authorized by the department.  
(4) On or before January 1 of the survey year, the department shall provide in writing an  
approval or denial of the waiver from licensure survey to the licensee.  
COMMENTS – Has the Department completed the procedure to request a waiver and  
made that publicly available?  
Rule 1331Policies and Procedures  
(2)(e) Discharge, including aftercare. The policy and procedure may not permit  
discharge of a recipient due to a return to use so long as the recipient reengages in  
treatment and complies with program policies and treatment protocol prospectively.  
COMMENT: We understand the intent behind a policy like this for a chronic, relapsing  
disorder. As written, it seems overly broad and difficult to apply to all treatment settings.  
There are some instances that a return to use also involves a breach of program policies  
and/or rules. What happens if an individual smuggles in contraband to a residential  
facility and uses an illicit substance? For outpatient, what type of timeframe is allowable  
before a possible discharge? What evidence does there need to be to demonstrate  
compliance with policies and protocols?  
R 325.1363 Service Treatment plans, excluding CAIT and SARF.  
(1) Based upon the assessments made of a recipient's needs, a written treatment service  
plan, which may include both medical and counseling services, shall must be  
developed and recorded in the recipient's record. A treatment service plan shall must be  
developed by a licensed or certified professional as referenced in these rules and as  
promptly after the recipient's admission as feasible, but before the recipient is engaged in  
therapeutic activities. but no later than either of the following:  
(a) The conclusion of the next session attended by the client for outpatient  
counseling programs.  
(b) Twenty-four hours for methadone, residential, and residential withdrawal  
management programs.  
(2) A service plan must include the recipient’s signature agreeing to the plan and  
state when updates are made.  
COMMENT – It is not possible to complete a comprehensive service plan within 24  
hours of admission, especially for residential and residential withdrawal management  
programs. Often the full biopsychosocial assessment is not completed within 24 hours  
of admission to a withdrawal management program because the recipient is not capable  
of it. Also, proposed timeframes do not account for weekends or holidays. The only type  
An Affiliate Member Organization of the Community Mental Health Association of Michigan  
THE PROVIDER ALLIANCE  
4507 SOUTH GRAND AVE, LANSING, MI 48933  
of Service Plan that could be produced within that timeframe would be pretty cookie  
cutter types of initial plans to comply with the standard, but not personalized or very  
comprehensive. This is unrealistic and providers will not be able to comply.  
Additionally, to require this from an opioid treatment program within 24 hours of  
admission will cause delays in people receiving services. Programs will schedule  
individuals for their initial appointment with a physician often times without having a  
therapist available to conduct the assessment and complete a treatment plan the same  
day. Having an individual get started on his/her medication is a harm reduction strategy  
and is often utilized prior to a full biopsychosocial assessment being completed to not  
delay the admission.  
R 325.1381 Outpatient counseling services; program requirements.  
(6) A licensee shall ensure that a limited certified counselor in not responsible for  
more than 32 recipients.  
R 325.1383 Medication assisted treatment (MAT) services; Methadone program requirements.  
(6) A licensee shall ensure that a limited certified counselor in not responsible for  
more than 32 recipients.  
COMMENTS – (both 1381(6) and 1383 (6) – What information was used to determine  
that a limited certified counselor cannot be responsible for more than 32 recipients. The  
amount of services needed by each recipient is individualized. Additionally,  
organizations look at full time positions the same regardless of an individual’s  
credentials. Limited certified counselors should not be forced to have a reduced case  
size, and should not be treated differently that those with a limited license. This  
standard puts a substantial burden on rural and frontier SUD providers in particular  
where the workforce is already a significant challenge.  
R 325.1385 Residential program services; requirements.  
(5) A licensee shall ensure that a limited certified counselor is not responsible for  
more than 10 recipients.  
(58) A licensee shall provide and ensure recipient participation in at least not less than 15  
hours per week of treatment and support and rehabilitation services to meet the needs of  
the recipients to take place days, evenings, and weekends. Not less than At least 310 of  
the 15 hours must be treatment in the form of treatment or rehabilitation evidence-based  
practice or services individual counseling, group counseling, social skills training, cognitive  
behavioral therapy, motivational interviewing, couples counseling, or family counseling for  
each recipient. Participation shall must be documented in the recipient record.  
COMMENTS –  
1385(5) COMMENTS – (6) – What information was used to determine that a limited  
certified counselor cannot be responsible for more than 32 recipients. The amount of  
services needed by each recipient is individualized. Additionally, organizations look at  
full time positions the same regardless of an individual’s credentials. Limited certified  
An Affiliate Member Organization of the Community Mental Health Association of Michigan  
THE PROVIDER ALLIANCE  
4507 SOUTH GRAND AVE, LANSING, MI 48933  
counselors should not be forced to have a reduced case size, and should not be treated  
differently that those with a limited license. This standard puts a substantial burden on  
rural and frontier SUD providers in particular where the workforce is already a significant  
challenge.  
1385(8) It is risky for LARA to be setting one standard to cover the multiple levels of  
residential treatment programs that are recognized by federal experts like ASAM and  
CARF. For example, the hours per week requirement goes above what is required by  
the American Society of Addiction Medicine for ASAM Residential Level III.1 and what is  
required by the MDHHS. However, it is well below the requirements of 40 hours of  
support and treatment for ASAM Residential Level III.5 as required by MDHHS.  
R 325.1388 Residential Withdrawal management program requirements.  
(2) A program offering clinically managed withdrawal management services offers  
peer and social support services only and not offer or administer schedule II-V  
controlled substances for the management of withdrawal, including methadone and  
buprenorphine.  
(4) A residential withdrawal management program shall meet all of the following  
requirements:  
(c) A physician, physician’s assistant, or advanced practice registered nurse shall  
review and assess each recipient upon admission and every 72 hours after the  
initial review and assessment to determine if the recipient is suitable for the  
services being offered. If a recipient is referred from a licensed acute care  
hospital, psychiatric unit, or hospital directly to a licensed residential withdrawal  
management program, the transfer documentation, including the health  
assessment from the transferring hospital, may be used as the initial assessment  
for admission if all of the following are met:  
(6) A residential withdrawal management program offering medically monitored  
withdrawal management services must also meet both of the following requirements:  
(a) A licensee shall have a physician, physician’s assistant, or advanced practice  
registered nurse complete and document the medical and drug history, as well as  
a physical examination of the recipient, before administering any medications. In  
addition, any modification to medications or course of treatment must be  
documented in the recipient record and ordered by a physician, physician’s  
assistant, or advanced practice registered nurse.  
COMMENT:  
1388(2) - Why are clinically managed withdrawal management programs not allowed to  
utilize medications that are allowed to be prescribed by primary care offices? Would a  
program be in violation of this standard if the program staff were supervising the self-  
administration of prescribed medications and that trained staff are taking medication  
according to prescription and legal requirements as defined with the State of Michigan’s  
Medicaid Manual as well as the national standards of ASAM and CARF?  
An Affiliate Member Organization of the Community Mental Health Association of Michigan  
THE PROVIDER ALLIANCE  
4507 SOUTH GRAND AVE, LANSING, MI 48933  
1388(4)(c) - Requiring a physician, physician’s assistant, or advanced practice  
registered nurse to review and assess each recipient upon admission is exceeding the  
level of medical care required by the American Society of Addiction Medicine for this  
level of care. Well run withdrawal management programs have the recipient seen by  
these providers within 24 hours of admission after being evaluated by their trained  
designee. As stated in the ASAM Criteria, a physician (or physician extender) should be  
“available to assess the patient within 24 hours of admission.” ASAM Criteria states, a  
registered nurse or other licensed and credentialed nurse is available to conduct a  
nursing assessment on admission. This requirement forces providers to limit admissions  
to those hours a physician or mid-level is available which impacts access to services and  
is not a national requirement. Individuals scheduled for admission into this level of care  
rarely arrive at their scheduled appointment time. Providers do not turn someone away  
who misses his/her appointment, but typically do not have physicians and/or mid-levels  
available to complete an initial assessment at the time of admission which could be 24  
hours per day.  
1388(6)(a) Requiring physical examinations prior to administering any medication  
exceeds the level of medical care necessary for this level of treatment. As stated in  
ASAM Criteria, a physician (or physician extender) should be “available to assess the  
patient within 24 hours of admission.” ASAM Criteria states, a registered nurse or other  
licensed and credentialed nurse is available to conduct a nursing assessment on  
admission. This requirement forces providers to limit admissions to those hours a  
physician or mid-level is available which impacts access to services and is not a national  
requirement. Individuals scheduled for admission into this level of care rarely arrive at  
their scheduled appointment time. Providers do not turn someone away who misses  
his/her appointment, but typically do not have physicians and/or mid-levels available to  
complete an initial assessment at the time of admission which could be 24 hours per  
day.  
R 325.1393 Treatment Service plan; specific recipient rights.  
(3) Unless notified in writing before admission, a recipient may utilize medications as  
prescribed by a physician.  
COMMENTS – This language is overly broad and creates a liability to the provider. It  
does not distinguish between medications that may have been prescribed by a physician  
through that program or if it is reference medications from a recipient’s primary care  
physician. A provider is not always made aware of prescribed medications at the time of  
admission if the individual does not present with the medication or indicate all prescribed  
medications in the outpatient level of care, especially medication assisted treatment.  
Additionally, medications can be prescribed after admitted to a program. The proposed  
language would restrict a program from safely managing care.  
Again, we appreciate many of the changes that LARA has proposed making to the  
Administrative Rules in this second phase of revision. The changes proposed could assist SUD  
provider to expand to help our State in its continued efforts to combat the opioid epidemic. The  
An Affiliate Member Organization of the Community Mental Health Association of Michigan  
THE PROVIDER ALLIANCE  
4507 SOUTH GRAND AVE, LANSING, MI 48933  
changes that we have suggested do not jeopardize the health and safety of individuals receiving  
SUD services. The changes will further improve access to the system of care, promote  
responsible development of the SUD workforce and are consistent with the ASAM Patient  
Placement Criteria, the Michigan Medicaid Manual and the policies of the Michigan Department  
of Health and Human Serivces. If LARA is willing to make some additional changes to its  
proposed draft, Michigan will have a set of rules that will be relevant for many years to come.  
Again, thank you for the work that you have done on revising the rules and your consideration of  
the feedback received by the many stakeholders throughout the state.  
Sincerely,  
Sam Price  
Sam Price, MA  
SUD Board Chair, The Provider Alliance  
President/CEO, Ten16 Recovery Network  
Provider Alliance SUD Members:  
Addiction Treatment Services  
Arbor Circle  
Hope Network  
Odyssey Village  
Bear River Health  
CARE of Southeast Michigan  
Catholic Charities  
Ottagan Addiction Recovery (OAR)  
Pine Rest  
Sacred Heart  
Easterseals Michigan  
Great Lakes Recovery Network  
Harbor Hall  
Ten16 Recovery Network  
The Recovery Center; CEI Mental  
Health Authority  
Hegira Health  
The Phoenix House  
An Affiliate Member Organization of the Community Mental Health Association of Michigan  
Larry Horvath, Bureau of Community and Health Systems  
Department of Licensing and Regulatory Affairs  
Lansing, MI  
Dear Larry,  
I appreciate the long work that your team has been putting into getting the new Administrative Rules  
finalized. I also appreciate your willingness to take the feedback from providers in the field to inform  
your decisions.  
There are a few final comments that Ten16 would share for the Department’s consideration:  
R 325.1301 Definitions.  
(u) “Limited certified counselor” means an individual who is employed or who volunteers to  
work providing counseling to recipients in a substance use disorder services program  
licensed by the department under part 62 of the public health code, MCL 333.6230 to  
333.6251, and who has completed a minimum set of state-approved requirements before  
completing the necessary prerequisites to become a certified alcohol and drug counselor by  
an organization approved or recognized by the department.  
COMMENT – (u) It will be critical to understand what the state-approved requirements would be  
and how soon an individual would be able to earn that limited status. It will be a challenge going  
forward employing people in this status while they are working toward their limited credential  
because we may not have a means to be reimbursed for services. While I understand the need  
to eliminate the abuses that unscrupulous providers by manipulating the Development Plan, I  
think the unintended consequence of this hurts rural and frontier providers who don’t have a  
large talent pool of licensed professionals. Additionally, it hurts the career path for those with  
lived experience to contribute to the field by blocking the ways that providers can use their skills  
while supervising their professional development  
R 325.1363 Service Treatment plans, excluding CAIT and SARF.  
(1) Based upon the assessments made of a recipient's needs, a written treatment service plan,  
which may include both medical and counseling services, shall must be developed and  
recorded in the recipient's record. A treatment service plan shall must be developed by a licensed  
or certified professional as referenced in these rules and as promptly after the recipient's  
admission as feasible, but before the recipient is engaged in therapeutic activities. but no later  
than either of the following:  
(b) Twenty-four hours for…..residential…programs.  
COMMENT – It is not possible to complete a comprehensive service plan within 24 hours of  
admission, especially for residential treatment programs. Often because of the recipient’s  
condition, a full biopsychosocial assessment may be difficult to complete within 24 hours of  
admission to these programs. The result of a standard like this will result in a basic, cookie  
cutter initial plan to satisfy the regulation and then a more personalized, comprehensive service  
plan. The PIHPs have a 72 hour standard to complete the Service Plan. While it can be a  
challenge even then, it is more realistic. Also, the proposed timeframes for all three programs  
being required to meet the 24 hour standard do not account for weekends or holidays.  
ADMIN - 133 N SAGINAW RD, MIDLAND, MI 48640 P: 989-631-0241 F: 989-835-9963  
RESIDENTIAL RECOVERY HOUSING OUTPATIENT PEER SUPPORT COLLEGIATE RECOVERY OUTREACH PREVENTION  
ARENAC BAY CLARE GLADWIN GRATIOT ISABELLA MECOSTA MIDLAND OGEMAW OSCEOLA SAGINAW  
AN EQUAL OPPORTUNITY PROVIDER  
R 325.1381 Outpatient counseling services; program requirements.  
(6) A licensee shall ensure that a limited certified counselor in not responsible for more than  
32 recipients.  
R 325.1383 Medication assisted treatment (MAT) services; Methadone program requirements.  
(6) A licensee shall ensure that a limited certified counselor in not responsible for more than  
32 recipients.  
COMMENT – (both 1381(6) and 1383 (6) – Limited certified counselors should not be forced to  
have a reduced case size, and should not be treated differently that those with a limited license.  
This standard puts a substantial burden on rural and frontier SUD providers in particular where  
the workforce is already a significant challenge.  
R 325.1385 Residential program services; requirements.  
(58) A licensee shall provide and ensure recipient participation in at least not less than 15 hours  
per week of treatment and support and rehabilitation services to meet the needs of the  
recipients to take place days, evenings, and weekends. Not less than At least 310 of the 15 hours  
must be treatment in the form of treatment or rehabilitation evidence-based practice or  
services individual counseling, group counseling, social skills training, cognitive behavioral therapy,  
motivational interviewing, couples counseling, or family counseling for each recipient. Participation  
shall must be documented in the recipient record.  
COMMENTS – It is risky for LARA to be setting one standard to cover the multiple levels of  
residential treatment programs that are recognized by federal experts like ASAM and CARF.  
For example, the hours per week requirement goes above what is required by the American  
Society of Addiction Medicine for ASAM Residential Level III.1 and what is required by the  
MDHHS. However, it is well below the requirements of 40 hours of support and treatment for  
ASAM Residential Level III.5 as required by MDHHS.  
R 325.1388 Residential Withdrawal management program requirements.  
(2) A program offering clinically managed withdrawal management services offers peer and  
social support services only and not offer or administer schedule II-V controlled substances  
for the management of withdrawal, including methadone and buprenorphine.  
COMMENT - Why are clinically managed withdrawal management programs not allowed to  
utilize medications that are allowed to be prescribed by primary care offices? Would a program  
be in violation of this standard if the program staff were supervising the self-administration of  
prescribed medications and that trained staff are taking medication according to prescription  
and legal requirements as defined with the State of Michigan’s Medicaid Manual as well as the  
national standards of ASAM and CARF?  
If LARA is willing to accept the “supervision of self-administration” for medications that are  
prescribed and dispensed to a recipient, then the current language makes sense. But it is  
critical to understand how the language will be interpreted and applied.  
ADMIN - 133 N SAGINAW RD, MIDLAND, MI 48640 P: 989-631-0241 F: 989-835-9963  
RESIDENTIAL RECOVERY HOUSING OUTPATIENT PEER SUPPORT COLLEGIATE RECOVERY OUTREACH PREVENTION  
ARENAC BAY CLARE GLADWIN GRATIOT ISABELLA MECOSTA MIDLAND OGEMAW OSCEOLA SAGINAW  
AN EQUAL OPPORTUNITY PROVIDER  
(4) A residential withdrawal management program shall meet all of the following  
requirements:  
(c) A physician, physician’s assistant, or advanced practice registered nurse shall review  
and assess each recipient upon admission and every 72 hours after the initial review and  
assessment to determine if the recipient is suitable for the services being offered. If a  
recipient is referred from a licensed acute care hospital, psychiatric unit, or hospital  
directly to a licensed residential withdrawal management program, the transfer  
documentation, including the health assessment from the transferring hospital, may be  
used as the initial assessment for admission if all of the following are met:  
COMMENT - Requiring a physician, physician’s assistant, or advanced practice registered  
nurse to review and assess each recipient upon admission is exceeding the level of medical  
care required by the American Society of Addiction Medicine for this level of care. Well run  
withdrawal management programs have the recipient seen by these providers within 24 hours of  
admission after being evaluated by their trained designee. As stated in the ASAM Criteria, a  
physician (or physician extender) should be “available to assess the patient within 24 hours of  
admission.” ASAM Criteria states, a registered nurse or other licensed and credentialed nurse  
is available to conduct a nursing assessment on admission. This requirement forces providers  
to limit admissions to those hours a physician or mid-level is available which impacts access to  
services and is not a national requirement. Individuals scheduled for admission into this level of  
care rarely arrive at their scheduled appointment time. Providers do not turn someone away  
who misses his/her appointment, but typically do not have physicians and/or mid-levels  
available to complete an initial assessment at the time of admission which could be 24 hours  
per day.  
Again, thank you for the work that you have done on revising the rules and your consideration of the  
feedback received by the many stakeholders throughout the state.  
Sincerely,  
Samuel D Price, MA  
President/CEO  
ADMIN - 133 N SAGINAW RD, MIDLAND, MI 48640 P: 989-631-0241 F: 989-835-9963  
RESIDENTIAL RECOVERY HOUSING OUTPATIENT PEER SUPPORT COLLEGIATE RECOVERY OUTREACH PREVENTION  
ARENAC BAY CLARE GLADWIN GRATIOT ISABELLA MECOSTA MIDLAND OGEMAW OSCEOLA SAGINAW  
AN EQUAL OPPORTUNITY PROVIDER  
Date: August 30, 2022  
Larry Horvath, Director  
Bureau of Community and Health Systems  
MI Department of Licensing and Regulatory Affairs  
611 West Ottawa Street  
P.O. Box 30664  
Lansing, MI 48909  
Dear Mr. Horvath:  
On behalf of Great Lakes Recovery Centers, please accept these written comments as part of the  
public testimony on the proposed changes to the Administrative/Licensing Rules for Substance Use  
Disorder Services Programs, Phase II.  
Great Lakes Recovery Centers is a nationally accredited long-standing provider of SUD residential  
treatment, detox, and outpatient services in many of the most rural communities across the State of  
Michigan, representing the Upper Peninsula.  
I would like to begin by saying thank you to you and your staff for the time and consideration that has  
went into the process of evaluating the standards. You were willing to meet with us and made the  
time to better understand the impact that Phase I of the rule set changes had on services in the State.  
You have listened to provider needs over the past two years and we appreciate the ability to work  
with LARA on the crafting of meaningful SUD standards.  
With the current proposed rule set, we have the following items for consideration:  
Item #1: Brach Office Distance  
R 325.1304 Application for branch office or mobile unit; requirements; review process;  
approval.  
Item 1. 4.d The branch office is located within 75 miles from the parent location.  
We would like for additional consideration with increasing the allowable mileage to 100 miles for  
extreme rural or frontier communities, especially those seen the Upper Peninsula and Norther Lower  
Michigan. We have offices that can be more than 75 miles apart that are limited use and operate as  
a branch or satellite location. These offices are sometimes the only source of support for people  
needing access to care.  
1
Item #2: Residential Withdrawal Management:  
R 325.1388 Residential withdrawal management program requirements.  
R325.1388(2). (2) A program offering clinically managed withdrawal management services  
shall offer peer and social support services only and not offer or administer schedule II-V  
controlled substances, as classified under 21 USC 812, for the management of withdrawal,  
including methadone and buprenorphine.  
We are seeking the rescinding of R325.1388(2), or, a defined interpretation for programs that offer  
clinically managed residential withdrawal programming, (i.e. Social Detox), that the use of self-  
administered medications be allowed. We would like direction from LARA that the interpretation and  
enforcement of the language around controlled substances would allow programs to supervise an  
individual self-administering medication including controlled substances used to manage withdrawal  
symptoms. This is with the understanding that the medications are labeled, dispensed prescriptions  
in bottles with the individual’s name on them from an independent pharmacy.  
This practice would be in line state and federal program standards for Clinically Managed Withdrawal  
Management (ASAM Level 3.2) which all allow for the supervision of a person taking of their own  
prescribed medication in this level of programming. This includes:  
MDHHS/Michigan Medicaid Program Standards, Treatment Policy 13, p.6  
American Society for Addiction Medicine (ASAM), p.43  
U.S. Substance Abuse Mental Health Service Administration (SAMHSA), Detoxification  
and Substance Abuse Treatment, Treatment Improvement Protocol #45  
Carf (Commision on Accreditation of Rehabilitation Facilities) 2022 Behavioral Health  
Standards Manual, Section 2.e.2  
This interpretation and application of R325.1388(2), to allow the supervision of self-administration,  
would be critical to allow for individuals who are directly transferred from a licensed acute care,  
psychiatric unit, or hospital as referenced in R325.1388(4). Many of these individuals may leave that  
facility with prescribed medications to manage their symptoms. These medications would be labelled  
and dispensed by an independent pharmacy.  
Additionally, there is a contradictory statement in Part 5: Recipient Rights, that states the following:  
(3) Unless notified in writing before admission, a recipient may utilize medications as  
prescribed by a physician.  
2
Item 3: Service Plan Timeline  
R 325.1363 Service Treatment plans, excluding CAIT and SARF.  
Rule 1363. (1) Based upon the assessments made of a recipient's needs, a written treatment  
service plan, which may include both medical and counseling services, shall must be  
developed and recorded in the recipient's record. A treatment service plan shall must be  
developed by a licensed or certified professional as referenced in these rules and as promptly  
after the recipient's admission as feasible, but before the recipient is engaged in therapeutic  
activities. but no later than either of the following:  
(b) Twenty-four hours for methadone, residential, and residential withdrawal management  
programs.  
In reference to the development of service plans within 24 hours for residential and residential  
withdrawal management programs, the nature of a comprehensive service plan being developed  
within 24 hours presents operational challenges for programs. Within treatment programs, the ability  
to compete a comprehensive bio-psycho-social assessment is a key component in the development  
of a well-crafted service plan. The time it takes to process this information with the client that results  
in (1) comprehensive service plan often requires more time that 24 hours. The suggested time  
interval is that the service plan would be completed within 48-62 hours.  
Item 4: Limited Certified Counselor  
(t) “Limited certified counselor” means an individual who is employed or who volunteers to  
work providing counseling to recipients in a substance use disorder services program  
licensed by the department under part 62 of the public health code, MCL 333.6230 to 333.6251,  
and who has completed a minimum set of state-approved requirements before completing the  
necessary prerequisites to become a certified alcohol and drug counselor by an organization  
approved or recognized by the department.  
Outpatient: A licensee shall ensure that a limited certified counselor is not responsible for  
more than 32 recipients.  
Residential: A licensee shall ensure that a limited certified counselor is not responsible for  
more than 10 recipients.  
With respect to counselor capacities in Outpatient and Residential Services, the revised, more  
limiting, case load distinctions are a bit concerning. With reductions to the Substance Use Disorder  
counselor field, given restrictions imposed by the Michigan Certification Board for Addiction  
Professionals (MCBAP), based on interpterion of LARA intentions, will reduce the number of potential  
3
applicants for certification. The mis-interpretation of applying licensed mental health credentialing  
requirements to Substance Use Disorder professionals, is resulting in fewer eligible counselors. With  
fewer counselors available, the reduction of case load sizes will have a detrimental impact to  
treatment providers.  
We would like to see no change in distinction with case load sizes for limited certified counselors  
compared to other limited licensed professionals listed in the rule set. It would appear to be a  
discriminatory distinction, as both sets of limited licensed/certified staff receive required clinical  
supervision.  
Thank you in advance for your time and in reviewing this information and for consideration of the  
items outlined. I can be reached via phone at (906) 228-9694, or via email at:  
gtoutant@greatlakesrecovery.org  
Respectfully submitted,  
Greg Toutant, CEO  
4
August 30, 2022  
Michigan Department of Licensing and Regulatory Affairs  
Bureau of Community and Health Systems  
Attn: Tammy Bagby  
PO Box 30664  
Lansing, MI 48909  
RE: Proposed changes to administrative rules for Substance Use Disorder Service Programs, R  
325.1301 - R 325.1399  
On behalf of the Vital Strategies Overdose Prevention Program, we write to express our support for the  
Department of Licensing and Regulatory Affairs (“LARA”), Bureau of Community and Health Systems’  
(“Bureau”) proposal to revise its regulations governing Substance Use Disorder Service Programs in  
Michigan. Vital Strategies is a global public health organization working with governments and  
communities in over 70 countries to help reduce preventable deaths, bringing expertise and technical  
assistance on issues like cardiovascular health, road safety, tobacco control, food policy, and drug  
overdose. Our organization is the lead partner in the Bloomberg Overdose Prevention Initiative, and we  
have been engaged intensively in the state of Michigan since early 2019. We look forward to continuing  
work with state, tribal, and local governments, providers, and community organizations in the coming  
years to support an equitable and sustainable reduction in overdoses in Michigan.  
Amidst the COVID-19 pandemic, the country’s drug overdose crisis has reached tragic new heights.  
The latest data from the Centers for Disease Control and Prevention (“CDC”) show that overdose  
deaths in the United States continue to rise and, for the first time ever, surpassed 100,000 deaths in a  
single year.1 Michigan saw a more than 24% increase in overdose deaths from 2019 to 2021, which  
was largely driven by opioids.2,3 Treatment for opioid use disorder (OUD) with agonist medications  
buprenorphine and methadone4 is most effective at reducing overdose and serious opioid-related acute  
care relative to other treatments, such as naltrexone or inpatient detoxification or residential services.5  
Agonist medications for OUD are associated with an estimated mortality reduction of 50% among  
people with OUD,6 supporting the conclusion of the National Academies of Sciences, Engineering, and  
1 Ahmad FB, Cisewski JA, Rossen LM, Sutton P. Provisional drug overdose death counts. National Center for Health  
Statistics. 2022. Designed by LM Rossen, A Lipphardt, FB Ahmad, JM Keralis, and Y Chong: National Center for Health  
Statistics.  
2 Number of Drug Poisoning/Overdose Deaths - Selected year(s). MiTracking. Michigan Department of Health and Human  
Services. https://mitracking.state.mi.us/?bookmark=238. Accessed August 26, 2022.  
3 Michigan Overdose Data to Action Dashboard. Michigan.gov website. https://www.michigan.gov/opioids/category-data.  
Accessed August 26, 2022.  
4 Also referred to throughout as “MOUD,” meaning medications for opioid use disorder. MOUD is synonymous with medication  
assisted treatment, or “MAT.”  
5 Wakeman SE, Larochelle MR, Ameli O, et al. Comparative Effectiveness of Different Treatment Pathways for Opioid Use  
Disorder. JAMA Netw Open. 2020;3(2):e1920622.  
6 Sordo L, Barrio G, Bravo MJ, et al. Mortality risk during and after opioid substitution treatment: Systematic review and meta-  
analysis of Cohort studies. BMJ. 2017.  
Medicine in 2019 that “[t]he verdict is clear: effective agonist medication used for an indefinite period of  
time is the safest option for treating OUD.”7  
LARA’s proposed changes to the administrative rules for Substance Use Disorder Service Programs  
would expand and enhance critical, life-saving access to agonist medications among Michiganders with  
OUD. Vital Strategies submits this comment to outline its support for key changes in the draft rules and  
offer several recommendations on how the rules can be further clarified or strengthened.  
I. Key improvements in the proposed rules  
a. Eliminating licensure barriers for prescribers of buprenorphine and facilitating  
access for recipients  
Widespread access to the agonist medication buprenorphine is an essential overdose prevention and  
health promotion strategy. Providers who prescribe buprenorphine for OUD are already subject to  
unique federal requirements that have been identified as a barrier to addressing the enormous unmet  
need for evidence-based OUD treatment.8,9,10,11 It is imperative that states not impose additional  
regulatory barriers that may further discourage providers from offering this life-saving medication to  
people with OUD.  
Vital Strategies applauds the proposed elimination of Rule 325.1303(3)(c) and of related provisions that  
currently impose an additional licensure requirement under certain circumstances for buprenorphine  
prescribing to treat OUD. Moreover, Proposed Rule 325.1331(2)(c) requires that applicants and  
licensees maintain policies and procedures that include “referrals, including access to medication-  
7 National Academies of Sciences, Engineering, and Medicine. Medications for opioid use disorder save lives. (Leshner AI,  
Mancher M, eds.). Washington, DC: The National Academies Press; 2019.  
8 The Drug Addiction Treatment Act of 2000 (DATA 2000) and its implementing regulations require practitioners to receive a  
separate registration (commonly referred to as an X waiver) prior to prescribing buprenorphine for the treatment of opioid use  
disorder. 21 USC § 823(g)(2). Only certain types of practitioners are eligible to receive an X waiver and must meet specified  
certification or training requirements. 21 USC § 823(g)(2)(G)(ii)-(iv). Practitioners must attest to their capacity to provide,  
directly or by referral, appropriate counseling and other appropriate ancillary services. 21 USC § 823(g)(2)(B)(ii)(II).  
Additionally, providers are restricted in the number of patients they may treat with buprenorphine at any given time, 21 USC §  
823(g)(2)(B)(iii), with further requirements related to practice setting and ancillary services for practitioners with higher patient  
limits. See 42 CFR § 8.610-.655. Practice guidelines issued by the Department of Health and Human Services in April 2021  
removed some, but not all, of these barriers for practitioners treating no more than 30 patients for OUD using buprenorphine,  
and all practitioners are still required to obtain an X waiver prior to prescribing buprenorphine for OUD. 86 Fed. Reg. 22439.  
9 Haffajee RL, Bohnert ASB, Lagisetty PA. Policy Pathways to Address Provider Workforce Barriers to Buprenorphine  
Treatment. American Journal of Preventive Medicine. 2018;54(6):S230-S242.  
10 Fiscella K, Wakeman SE, Beletsky L. Buprenorphine Deregulation and Mainstreaming Treatment for Opioid Use Disorder.  
JAMA Psychiatry. 2019;76(3):229. doi:10.1001/jamapsychiatry.2018.3685  
11 Oesterle TS, Thusius NJ, Rummans TA, Gold MS. Medication-assisted treatment for opioid-use disorder. Mayo Clinic  
Proceedings. 2019;94(10):2072-2086. "[I]t is estimated that only 11% of patients with an opioid use disorder are prescribed  
Food and Drug Administration (FDA)-approved medications for the disorder."  
2
assisted treatment” and that “[t]he policy and procedure must facilitate access to medication-assisted  
treatment if desired by the recipient.” Proposed Rule 325.1359(1)(a) similarly requires that a licensee  
include MOUD as a component of its assessment regarding support services if medication is not  
offered on site. This patient-centered approach will help ensure that those who desire it are connected  
with evidence-based medication treatment, even when seeking care from programs that do not offer  
this treatment modality directly.  
b. Authorizing and/or clarifying operation of branch and mobile units to reach  
underserved communities and promoting diverse service models  
In a recent survey conducted by LARA and Vital Strategies of more than 600 Michigan providers,  
approximately 41% of participants indicated that the addition of a satellite office or mobile unit to their  
practice could facilitate increased buprenorphine prescribing.12 In the context of insufficient treatment  
capacity more broadly, challenges to agonist medication access may be even more pronounced in rural  
areas due to geographic, transportation, and financial barriers.13 A 2018 study found that among  
Michigan counties that lacked MOUD treatment services, nearly all counties were concentrated in the  
state’s northern and primarily rural areas.14  
Proposed Rule 325.1304, which would authorize and/or clarify the operation of branch and mobile units  
in the state, is an important step toward increased MOUD access in rural and underserved areas in  
Michigan.  
c. Promoting naloxone access  
Naloxone, a medication which can rapidly reverse an opioid overdose and prevent death, should be  
widely accessible to communities, particularly people who use drugs and their networks. In 2017, only  
the state of Arizona had sufficient naloxone kits available to achieve a target of naloxone use in 80% of  
witnessed overdoses.15 In the state of Michigan, just over half of Michigan pharmacies offer naloxone  
12 Lyle V. Buprenorphine Prescribing Practices, Barriers & Facilitators: Survey Summary Report. (Cohen S, ed.). Michigan  
Department of Licensing and Regulatory Affairs (LARA) and Vital Strategies; 2022:28. Accessed August 26, 2022.  
https://www.michigan.gov/lara/-/media/Project/Websites/lara/communications/Buprenorphine-Prescribing-Practices-Survey-  
Summary-2022.pdf.  
13 Sigmon SC. Access to Treatment for Opioid Dependence in Rural America: Challenges and Future Directions. JAMA  
Psychiatry. 2014;71(4):359–360.  
14 Bohnert A, Erb-Downward J, Ivacko T. Opioid Addiction: Meeting the Need for Treatment in Michigan. Poverty Solutions  
University of Michigan; 2019. Accessed August 26, 2022. https://poverty.umich.edu/files/2019/05/PovertySolutions-  
OpioidTreatment-PolicyBrief-r4.pdf.  
15 Irvine MA, Oller D, Boggis J, Bishop B, Coombs D, Wheeler E, Doe-Simkins M, Walley AY, Marshall BDL, Bratberg J, Green  
TC. Estimating naloxone need in the USA across fentanyl, heroin, and prescription opioid epidemics: a modelling study.  
Lancet Public Health. 2022 Mar;7(3):e210-e218  
3
without requiring a patient-specific prescription, despite a statewide standing order. Notably, areas with  
higher overdose fatality rates had fewer pharmacies offering naloxone via the standing order.16  
Proposed Rule 325.1331(2)(f) would require programs to offer naloxone kits to “recipients with a history  
of opioid use or who are otherwise determined to be at risk for overdose.” Establishing provision of  
naloxone to people at risk of overdose as a standard of care among licensed programs will better meet  
the needs of Michiganders, and importantly gets the overdose antidote directly into the hands of those  
at risk.  
d. Aligning state standards for methadone treatment with federal law  
Methadone, although highly effective as treatment for OUD, is constrained by a restrictive federal  
regulatory scheme. For example, federal regulations stipulate requirements for patient admission,  
frequency of drug testing, and allowance of take-home medication.17 Michigan’s current regulations for  
methadone programs exceed these already-restrictive federal standards around provision of care,  
particularly with respect to drug testing frequency18 and permitted take-home doses.19  
16 Dahlem CH, Myers M, Goldstick J, et al. Factors associated with naloxone availability and dispensing through Michigan’s  
pharmacy standing order. The American Journal of Drug and Alcohol Abuse. 2022:1-10.  
17 See 42 CFR §§ 8.12(e), 8.12(f)(6), 8.12(i)(2)-(3).  
18 Michigan’s current regulations require licensees to conduct random biweekly drug testing until a recipient has maintained  
biweekly drug-free results for a period of six months, after which a licensee must continue random monthly testing (a minimum  
of 18 drugs tests in the first year of treatment). Mich. Admin. Code r. 325.1383(14)(b)-(c). A recipient with a positive drug test  
must undergo weekly testing until the licensee documents three consecutive weekly drug-free results. Mich. Admin. Code r.  
325.1383(14)(d). This contrasts with federal regulations, which require only eight random drug tests per year, with no  
requirement for additional drug tests based on a positive result. 42 CFR § 8.12(f)(6).  
19 This table compares the time-in-treatment requirements for take-home dosages under current Michigan regulations, Mich.  
Admin. Code r. 325.1383(15)(b), and federal regulations, 42 CFR § 8.12(i)(3). Note the significant departure of Michigan  
regulations from the federal standard starting at Day 271 of treatment.  
Time in Treatment Michigan  
Federal  
1-90 Days 1 Dose/week  
91-180 Days 2 Doses/week  
181-270 Days 3 Doses/week  
271-365 Days 3 Doses/week  
366-730 Days 4 Doses/week  
731-1,095 Days 5 Doses/week  
1,096-1,825 Days 6 Doses/week  
1 Dose/week  
2 Doses/week  
3 Doses/week  
6-day supply  
2-week supply  
One-month supply  
One-month supply  
1,826+ Days 2, 13 Doses/month One-month supply  
The table does not account for flexibilities in take-home doses authorized by the Substance Abuse and Mental Health Service  
Administration (SAMHSA) during the COVID-19 pandemic, which SAMHSA has announced will be extended and made  
permanent. See Methadone Take-Home Flexibilities Extension Guidance. Substance Abuse and Mental Health Services  
Administration (SAMHSA) website. https://www.samhsa.gov/medication-assisted-treatment/statutes-regulations-  
guidelines/methadone-guidance. Last Updated March 3, 2022. Accessed August 26, 2022.  
4
The agency’s proposed rules more closely align Michigan’s requirements for Opioid Treatment  
Programs with federal law (i.e., standards regarding frequency of drug testing and take-home  
medication).20 The proposed changes would make provision of methadone in the state lower barrier  
and easier for patients to access and remain in care.  
e. Discouraging recipient discharge solely for return to use  
Return to use, also commonly referred to as “relapse,” is a common reason for providers to discharge  
patients from buprenorphine treatment. The 2022 survey summary report from LARA and Vital  
Strategies describes how “the most common reason for terminating [buprenorphine] treatment was a  
positive drug screen for illicit drug use.”21 The National Institute on Drug Abuse defines addiction as “a  
chronic, relapsing disorder.”22 Furthermore, in a sample derived from a nationally representative  
database, nearly 6 in 10 people with OUD had polysubstance use.23 Effective, evidence-based  
treatment should employ compassionate, patient-centered responses to the combination of return to  
use as a normal feature of the recovery process, as well as the high prevalence of polysubstance use  
among people with OUD.  
Under LARA’s proposed rules, a licensee’s policies and procedures “may not allow discharge of a  
recipient due to a return to use as long as the recipient reengages in treatment and complies with  
program policies and treatment protocol prospectively.”24 Vital Strategies commends this provision of  
the proposed rules and its intent to discourage termination of treatment solely on the basis of a patient’s  
return to use.  
II.  
Recommendations to further clarify or strengthen the proposed rules  
a. Clarify and strengthen requirements regarding return to use and recipient  
discharge; consider the addition of similar protections on counseling  
The language in proposed Rule 325.1331(2)(e) is ambiguous and Vital Strategies recommends that it  
be clarified and strengthened. Under the proposed language of this rule, it is unclear whether a licensee  
must have an affirmative prohibition in its policies and procedures of recipient discharge for return to  
use. An alternative interpretation of this proposed rule would be that it simply proscribes a discharge  
20 Proposed Rule 325.1383(12) and strike of Rules 325.1383(14) and (15).  
21 Lyle V. Buprenorphine Prescribing Practices, Barriers & Facilitators: Survey Summary Report. (Cohen S, ed.). Michigan  
Department of Licensing and Regulatory Affairs (LARA) and Vital Strategies; 2022:33. Accessed August 26, 2022.  
https://www.michigan.gov/lara/-/media/Project/Websites/lara/communications/Buprenorphine-Prescribing-Practices-Survey-  
Summary-2022.pdf.  
22 National Institute on Drug Abuse. Drug Misuse and Addiction. National Institute on Drug Abuse. Published July 2020.  
https://nida.nih.gov/publications/drugs-brains-behavior-science-addiction/drug-misuse-addiction. (emphasis added).  
23 Hassan AN, Le Foll B. Polydrug use disorders in individuals with opioid use disorder. Drug Alcohol Depend. 2019 May  
1;198:28-33.  
24 Proposed Rule 325.1331(2)(e).  
5
policy that explicitly provides for recipient discharge based on return to use. The former reading is more  
protective of recipients and more likely to be adhered to by licensees. Additionally, the requirement of  
the proposed rule that a recipient prospectively comply with program policies and treatment protocol to  
be shielded from discharge based on return to use should be eliminated or, in the alternative, made  
more flexible and protective.  
Vital Strategies recommends proposed Rule 325.1331(2)(e) be revised to read:  
“This policy and procedure must prohibit discharge of a recipient due to a return to use.”  
Barring that, the proposed provision should at minimum be changed to:  
“This policy and procedure must prohibit discharge of a recipient due to a return to use as long  
as the recipient reengages in treatment and makes a good-faith effort to comply with program  
policies and treatment protocol prospectively.”  
Finally, Vital Strategies encourages the agency to consider the addition of a similar provision targeting  
discharge in response to a recipient declining counseling services. This could be accomplished with the  
following language:  
“This policy and procedure must prohibit discharge of a recipient due to the recipient declining  
counseling services.”  
Behavioral health interventions like counseling can be an important adjunct to the use of medications  
like buprenorphine but are not necessary for treatment efficacy.25,26,27 The American Society of  
Addiction Medicine (“ASAM”) recommends in its National Practice Guidelines that a patient’s decision  
to decline behavioral health treatment should not impede their access to medication treatment for  
OUD.28  
b. Ensure that the requirements for branch offices and mobile units promote  
expanded access to care and are not too restrictive  
While the proposed rules critically enable the operation of branch offices and mobile units, Vital  
Strategies recommends that the agency reexamine some of the limitations it proposes for these service  
modalities. Specifically, proposed Rule 325.1304 imposes the following constraints:  
25 Wakeman SE, Larochelle MR, Ameli O, et al. Comparative Effectiveness of Different Treatment Pathways for Opioid Use  
Disorder. JAMA Netw Open. 2020;3(2):e1920622.  
26 California Health Care Foundation (CHCF). Buprenorphine: An Overview for Clinicians; 2019:8. Accessed August 30, 2022.  
https://www.chcf.org/wp-content/uploads/2019/08/BuprenorphineOverviewClinicians.pdf.  
27 Larochelle MR, Bernson D, Land T, et al. Medication for opioid use disorder after nonfatal opioid overdose and association  
with mortality: A cohort study. Annals of Internal Medicine. 2018 Aug; 169(3):137.  
28 American Society of Addiction Medicine. The ASAM National Practice Guideline for the Treatment of Opioid Use Disorder:  
2020 Focused Update. 2020:37; Accessed August 30, 2022. https://www.asam.org/quality-care/clinical-guidelines/national-  
practice-guideline (” A patient’s decision to decline psychosocial treatment or the absence of available psychosocial treatment  
should not preclude or delay pharmacological treatment of opioid use disorder, with appropriate medication management.”)  
6
•
•
•
•
Branch offices may be open to recipients no more than 20 hours per week  
Branch offices must be located within 75 miles from the parent location  
The total number of branch offices may not exceed 3 locations for the parent organization  
The total number of mobile units may not exceed 3 for the parent organization  
These limitations will undermine the reach and impact of branch offices and mobile units in Michigan,  
particularly given the state’s size and the rurality of many of its regions. Vital Strategies advises that  
these limitations be eliminated or eased to maximize access to underserved areas of the state. For  
example, short of eliminating the limitations entirely, the rules could: authorize full-time (40 hours/week)  
operation of branch offices; increase geographic range of branch offices or at least enable exceptions  
to the 75-mile requirement with a written statement of need; increase the number of authorized branch  
offices and/or mobile units or, at minimum, enable exceptions upon written justification. The number,  
location, and operating parameters of branch offices and mobile units could also alternatively be  
included on a parent organization’s application for licensure.  
c. Limit the ability of licensees to force a recipient’s discontinuation of appropriately  
prescribed medication  
Proposed Rule 325.1393(3) provides that “[u]nless notified in writing before admission, a recipient may  
utilize medications as prescribed by a physician.” Vital Strategies recommends elimination of this  
proposed provision because is suggests that the rules are permissive of a licensee forcing a recipient to  
discontinue use of appropriately prescribed medication. Instead, the rules should require licensees to  
allow recipients to continue use of prescribed medications unless clinically contraindicated.  
Vital Strategies applauds the agency’s proposed rule and its intent to expand and enhance critical SUD  
treatment services throughout the state. We encourage LARA to consider our comment and  
suggestions for improving the proposed rule. Should you have any questions, please do not hesitate to  
contact jrwan@vitalstrategies.org.  
Sincerely,  
Julie Rwan, MPH  
Kathryn Boulton, JD, MPH  
Senior Technical Advisor  
Vital Strategies Overdose Prevention Program  
jrwan@vitalstrategies.org  
Senior Legal Technical Advisor  
Vital Strategies Overdose Prevention Program  
kboulton@vitalstrategies.org  
Esther Mae Rosner, LMSW  
Derek Carr, JD  
Program Manager  
Legal Technical Advisor  
Vital Strategies Overdose Prevention Program  
emaerosner@vitalstrategies.org  
Vital Strategies Overdose Prevention Program  
dcarr@vitalstrategies.org  
7
August 30, 2022  
Tammy Bagby  
Michigan Department of Licensing and Regulatory Affairs  
Bureau of Community and Health Systems  
611 West Ottawa Street  
Lansing, MI 48909  
RE: Proposed Rule Set 2021-90 LR Substance Use Disorder Service Programs  
Via Email: Lara-bchs-training@michigan.gov  
Dear Ms. Bagby:  
Thank you for the opportunity to provide comments on the proposed changes to the Substance Use  
Disorder Service Programs Rule Set, 2021-90 LR. Ascension Michigan supports many of the proposed  
revisions to the rules, however we have identified concerns which are outlined below.  
Positive proposed changes to the rule set identified:  
The draft rules include important changes that will improve access and quality of care for people with  
SUD in Michigan.  
●
Eliminating barriers to buprenorphine—the draft rules would eliminate the additional state  
licensure requirement related to the provision of buprenorphine. This change removes a potential  
barrier to expanded care across the state (e.g., proposed strike of Rule 325.1303(3)(c)). The  
proposed rules also require licensees to facilitate access to MOUD if desired by a recipient  
(proposed Rule 325.1331(2)(c)).  
●
●
●
Authorization of mobile and branch units—the draft rules authorize branch and mobile units,  
which will help increase access to care in underserved areas of the state (proposed Rule  
325.1304).  
Promoting naloxone access—the proposed rules require programs to offer naloxone kits to  
recipients at high risk of overdose, a key overdose prevention strategy (proposed Rule  
325.1331(2)(f)).  
Aligning methadone standards with federal law—the proposed rules more closely align Michigan’s  
requirements for Opioid Treatment Programs with federal law (i.e., around frequency of drug  
testing and requirements for takehomes) (proposed Rule 325.1383(12) and strike of Rules  
325.1383(14) and (15)).  
●
Discouraging discharge solely for return to use- under the proposed rules, a licensee’s policies  
and procedures may not allow a person’s discharge from a program due to a return to use as long  
as the person reengages in treatment and complies with program requirements (proposed  
325.1331(2)(e)).  
Concerns with proposed changes to the rule set identified:  
The regulations identified below are either not easily feasible or will have unintended adverse  
consequences.  
R 325.1331 (2)(e) - Discharge, including aftercare. This policy and procedure may not allow discharge of  
a recipient due to a return to use as long as the recipient reengages in treatment and complies with  
program policies and treatment protocol prospectively.  
We have concerns that the rule does not make a distinction between outpatient services and  
residential services. When looking at the policy from the outpatient perspective, the policy does  
appear clear and easily applicable for patients receiving care under outpatient services. However,  
there is a dual mandate in residential treatment services that requires that individual patients are  
receiving treatment, including ensuring a “safe treatment environment” for other patients at the  
same time. The concern is that if a patient brings illicit substances into a residential treatment  
facility, it affects other patients and has great potential to create an unsafe healing environment.  
Some of the most unsafe conditions identified in residential settings such as medically managed  
detoxification , inpatient rehabilitation services and halfway house services, occur when there are  
illicit substances brought in against policy rules which allows for uncontrolled use occurring with  
one or more patients. This return to use in a residential setting is detrimental for patients'  
treatment and can also regress SUD treatment progress for other individuals (either return to use,  
overdose, or intense distraction from treatment). The rule as proposed focuses on the individual  
but increases risk factors for the group at large receiving treatment, which may lead to violations  
of providing a safe treatment environment for other individuals receiving treatment.  
Possible solutions include making a distinction between outpatient and inpatient services (i.e. the  
statement as written applies well to outpatient services) or acknowledging that major safety  
policy violations that impact other patients in a residential setting may be a cause for discharge  
(this can be integrated with R 325.1393 (4)). As written, the policy may have material safety  
impacts.  
We propose including either a written statement that clearly identifies making a distinction  
between outpatient and inpatient services (i.e. the rule section applies to outpatient services as  
well) or include language that major safety policy violations, that impact other patients in a  
residential setting, may be a cause for discharge.  
R 325.1363 (1)(b) - Rule 1363. (1) - Based upon the assessment made of a recipient's needs, a written  
service plan, which may include both medical and counseling services, must be developed and recorded in  
the recipient's record. A service plan must be developed by a licensed or certified professional as  
referenced in these rules and as promptly after the recipient's admission as feasible, but no later than  
either of the following: (a) The conclusion of the next session attended by the client for outpatient  
counseling programs. (b) Twenty-four hours for methadone, residential, and residential withdrawal  
management programs.  
We view this rule does not adequately account for the condition of most patients admitted to a  
medically monitored residential withdrawal unit. In most cases, the condition in the first 24 hours  
is intoxication. For Ascension Brighton Center for Recovery, we find this is up to a breathalyzer of  
0.300, and in various stages of objectively measured withdrawal. A patient cannot be “cleared”  
psychiatrically for suicidal thinking until they are at 0.000 on a breathalyzer. Under the proposed,  
the rule is mandating the creation of detailed service plans with patients in various forms of  
intoxication which is neither medically nor legally appropriate. We strongly urge considerations  
regarding cognitive dysfunction and withdrawal, to defer major portions of service plan decision  
making, including medication management planning, therapy style, family session planning, etc.  
until the patient is clinically out of the intoxication and moderate withdrawal phase. We propose a  
breathalyzer count of 0.000, a Clinical Opiate Withdrawal Scale (COWS) score of < 12 and a  
Clinical Institute Withdrawal Assessment (CIWA) score of < 8. Making detailed service plans prior  
to this level of medical stability is harmful to the patient and will lend to the need for undue  
adjustments to the plan of care, and could be coercive.  
We propose including language exempting the specific level of care of medically managed  
residential withdrawal from this 24 hour rule where these types of situations are the most likely to  
occur. The rule can be applied to the other treatment settings in the proposed rules without the  
same level of risk of coercion (methadone, residential services without withdrawal management,  
and other outpatient services).  
R 325.1388 (6)(a) - A residential withdrawal management program offering medically monitored  
withdrawal management services must also meet both of the following requirements: (a) A licensee shall  
have a physician, physician’s assistant, or advanced practice registered nurse complete and document the  
medical and drug history, as well as a physical examination of the recipient, before administering any  
medications. In addition, any modification to medications or course of treatment must be documented in  
the recipient record and ordered by a physician, physician’s assistant, or advanced practice registered  
nurse.  
This rule has a major barrier to access to care. In most acute hospital settings, a full history and  
physical examination can be deferred for late afternoon and evening admissions until the  
following day (24 hours). If a patient is admitted late in the day to a medically monitored  
withdrawal management program and cannot start needed medications such as buprenorphine,  
lorazepam, phenobarbital or other withdrawal medications, this is a major safety concern.  
Withdrawal management using standardized medication protocols and scoring as previously  
mentioned (CIWA, COWS, etc.) is a well documented approach to the care of a patient in  
withdrawal in a safe manner. This proposed rule does not allow for nurse assessment which  
includes: physical examination; point of care testing like breathalyzers, COVID-19, urine drug  
screens; medical review including current medication, medication allergies, and history of  
complicated withdrawal symptoms. This nursing assessment along with board certified Addiction  
Medicine physician review is enough information to safely start highly standardized withdrawal  
management protocols safely and effectively.  
Although unintended, the proposed rule without modification would likely have adverse effects  
including the reduction of access to care by restricting the allowed admissions for only certain  
hours due to physician / Advanced Practice Providers availability and/or creating significant  
safety issues by denying patients’ access to medication management for withdrawal symptoms  
and thereby increasing Against Medical Advice (AMA) discharges and safety related events  
(seizures, delirium tremens, severe avoidable withdrawal morbidity, etc.).  
We propose including language to allow for nurse triage and assessment with physician oversight  
of the admissions process to increase access to care and lower the rates of complicated  
withdrawal to improve patient safety. We also urge the consideration to clarify in the rule set that  
there may be a window of 24 hours to complete the initial history and physical examination and  
that the initial history and physical examination should not hinder access to generally recognized  
medication-assisted treatment for withdrawal management.  
Please contact me at (586) 753-1120 or douglas.apple@ascension.org if you have any questions  
regarding these comments or if you need additional information.  
Sincerely,  
Douglas J. Apple, MD, MS, FHM  
Chief Clinical Officer, Ascension Michigan  
OFFICERS  
President  
Timothy Gammons, DO, FASAM  
President-Elect  
Lewei Lin, MD  
Treasurer  
Ismael D. Yanga, MD, FASAM  
Secretary  
John A. Hopper, MD, DFASAM, FAAP, FACP  
Advocacy Chair  
Cara A. Poland, MD, MEd, DFASAM  
August 31, 2022  
Tammy Bagby  
Department of Licensing and Regulatory Affairs  
Bureau of Community and Health Systems  
Ottawa Building  
611 W. Ottawa St  
Lansing, MI 48909  
Re: Comments on Rule Set 2021-90 LR, Administrative Rules for Substance Use Disorder Service  
Programs  
Dear Ms. Bagby,  
On behalf of the Michigan Society of Addiction Medicine (MISAM), the medical specialty society  
representing physicians and clinicians in Michigan who specialize in the prevention, treatment,  
and recovery from addiction, thank you for the opportunity to comment on this important topic.  
As the addiction and overdose epidemic continues to significantly impact our state, your efforts  
to support providers and ensure that individuals with substance use disorder (SUD) receive  
evidence-based treatments are greatly appreciated.  
On the whole, we strongly support the changes proposed in Rule Set 2021-90 LR, or the  
Administrative Rules for Substance Use Disorder Service Programs. We believe that this rule set  
will benefit patients and addiction providers and help expand access to care to patients at a time  
of desperate need. In particular, we fully support the change to decrease barriers to  
buprenorphine treatment and support clinicians to increase treatment access. Other changes to  
enhance access to naloxone, authorize mobile treatment units, align drug testing standards with  
federal requirements, and strengthen program retention also stand out as significant  
improvements. We commend you for addressing these important issues. We also appreciate the  
important efforts to balance the need to increase treatment while also working to promote high  
quality care.  
However, we have a few areas of potential concern and propose slight adjustments:  
R 325.1363 (1)(b), pertains to the timely development of recipient treatment service plans. The  
proposed rule requires the development of a treatment service plan “as promptly after the  
recipient's admission as feasible, but before the recipient is engaged in therapeutic activities.”  
While we understand the need to develop treatment plans as soon as possible, we are concerned  
that the inclusion of residential withdrawal management programs in this 24-hour treatment  
service plan requirement could impact their ability to provide stabilizing care. Especially when  
patients are experiencing acute symptoms of withdrawal, development of detailed treatment  
plans beyond medically safe detoxification could be challenging. In turn, we suggest that you  
consider exempting residential withdrawal management program from this 24-hour treatment  
service plan rule or provide some more flexibility in terms of timeline.  
Further, R 325.1388 (6) requires that qualified personnel complete and document a recipient’s  
medical and drug use history before administering any medication. We are concerned about the  
implications of this rule for immediate access to care, specifically in hospital and withdrawal  
management settings. In these fast-paced settings, qualified personnel must be empowered to  
exercise their best medical judgement to respond quickly and decisively. To prevent creating  
barriers to immediate medication for addiction treatment (MAT) for withdrawal management,  
we urge that you add flexibility for situations when patients may need urgent medication  
treatment. This might be done by either allowing for nurse triage and assessment with physician  
oversight or allow some window of time (e.g. 24 hrs) to complete the initial history and physical  
examination  
Finally R 325.1331 (2)(e) concerns discharge policies, including aftercare. Specifically, this policy  
discourages discharge of a recipient due to a return to use as long as the recipient willingly  
reengages in treatment and complies with program policies and treatment protocol. We fully  
agree with the intent of this rule. However, as written, the proposal does not distinguish  
between outpatient settings and more intensive residential inpatient settings. Some residential  
programs may have difficulty following this rule due to wanting to balance safety and treatment  
needs of other patients. As such, we request that you add a distinction between outpatient and  
residential settings to this rule, specifying that discharge based solely on return to use is  
undesirable in residential facilities but may need to be balanced with the promotion of a safe  
treatment environment for other participants of the program.  
MISAM is grateful to have been incuded as a collaborator throughout this process. We feel that  
the proposed rule set is a substantial step forward. And we hope to continue our engagement as  
it nears full implementation. Please do not hesitate to contact me at polandc2@msu.edu if there  
is any future support our organization can provide.  
Sincerely,  
Timothy Gammons, DO, FASAM  
President, Michigan Society of Addiction Medicine  
Cara A. Poland, MD, MEd, DFASAM  
Advocacy Chair, Michigan Society of Addiction Medicine  
August 31, 2022  
400 STODDARD RD.  
RICHMOND, MI 48062  
Bureau of Community and Health Systems  
Attention: Tammy Bagby  
P.O. Box 30664  
Lansing, MI 48909  
Lara-bchs-training@michigan.gov  
ADULT  
RESIDENTIAL  
& CLEARVIEW  
P: 810.392.2167  
F: 810.392.3530  
ALGONAC  
Dear Ms. Bagby:  
OUTPATIENT  
P: 810.987.1258  
F: 810.987.3505  
Thank you for the opportunity to provide feedback on the Department of Licensing and  
Regulatory Affairs proposed changes to the Substance Use Disorder Service Programs  
rule set.  
BAY CITY  
OUTPATIENT  
P: 989.894.2991  
F: 989.895.7669  
FLINT  
OUTPATIENT  
RECOVERY  
& WELLNESS  
P: 810.732.1652  
F: 810.732.1735  
Sacred Heart appreciates LARA making further updates to the rule set based on  
feedback dating back to 2018 and also feedback on drafts released within the past year.  
I am submitting feedback on behalf of Sacred Heart Rehabilitation Center, Inc from the  
review of the draft rule set dated June 23, 2022. Sacred Heart has been providing  
substance use disorder (SUD) services in Michigan since 1967. We are the largest SUD  
treatment provider for publicly funded adults in the state. We provide the full continuum  
of care at more than ten locations in Michigan. Sacred Heart is more than willing to  
participate in conversations regarding the feedback we provided, or as subject experts  
on future reviews of the rule set.  
MADISON HTS.  
OUTPATIENT  
RECOVERY  
& WELLNESS  
P: 248.658.1116  
F: 248.658.1120  
c
o
n
t
i
n
u
u
m
__________________________________________________________________  
NEW HAVEN  
OUTPATIENT  
P: 810.392.2167  
F: 810.392.3530  
The following feedback is based on the latest draft released:  
PORT HURON  
OUTPATIENT  
& RECOVERY  
HOUSING  
P: 810.987.1258  
F: 810.987.3505  
o
f
R 325.1301 Definitions.  
c
a
r
(t) “Limited certified counselor” means an individual who is employed or who volunteers  
to work providing counseling to recipients in a substance use disorder services program  
licensed by the department under part 62 of the public health code, MCL 333.6230 to  
333.6251, and who has completed a minimum set of state-approved requirements  
before completing the necessary prerequisites to become a certified alcohol and drug  
counselor by an organization approved or recognized by the department.  
SAGINAW  
e
OUTPATIENT  
P: 989.776.6000  
F: 989.776.1710  
SERENITY HILLS  
RECOVERY  
& WELLNESS  
CENTER  
P: 269.815.5500  
F: 269.815.5373  
COMMENT – (u) What are the state approved requirements?  
ST. CLAIR SHORES  
OUTPATIENT  
RECOVERY  
R 325.1301 Definitions.  
(w) “Methadone program” means a program engaged in opioid treatment of an individual  
with an opioid agonist treatment medication registered under 21 USC 823(g)(1),  
methadone.  
& WELLNESS  
P: 586.541.9550  
F: 586.204.3382  
ST. IGNACE  
OUTPATIENT  
RECOVERY  
& WELLNESS  
P: 906.984.2080  
F: 906.984.2190  
COMMENT - (w) Suggest referring to a program as an Opioid Treatment Program. This  
is the national recognition for a program that provides methadone. A provider cannot  
utilize methadone without obtaining federal certification called Opioid Treatment  
Program. Referringo a program as a “Methadone Program” is archaic and contributes to  
unnecessary stigma associated with the term methadone.  
sacredheartcenter.com  
Page 1 of 5  
R 325.1309 Waiver from licensure survey.  
Rule 1309. (1) The department shall provide and make publicly available a procedure  
for when a licensee may be eligible for a waiver from a licensure survey. The procedure  
must include maintaining a list of approved accrediting bodies for programs.  
(2) On or before October 1 of each year, the department shall publish a list of programs  
to receive a licensure survey in the next calendar year.  
(3) An eligible licensee may request a waiver from licensure survey on or before  
November 1 of each year. A waiver request shall be submitted on a form authorized by  
the department.  
(4) On or before January 1 of the survey year, the department shall provide in writing an  
approval or denial of the waiver from licensure survey to the licensee.  
COMMENTS – Does this exist? I do not see it listed on draft dated June 23, 2022.  
R 325.1363 Service Treatment plans, excluding CAIT and SARF.  
Rule 1363. (1) Based upon the assessments made of a recipient's needs, a written  
treatment service plan, which may include both medical and counseling services,  
shall must be developed and recorded in the recipient's record. A treatment service  
plan shall must be developed by a licensed or certified professional as referenced  
in these rules and as promptly after the recipient's admission as feasible, but before  
the recipient is engaged in therapeutic activities. but no later than either of the  
following:  
(a) The conclusion of the next session attended by the client for outpatient  
counseling programs.  
(b) Twenty-four hours for methadone, residential, and residential withdrawal  
management programs.  
(2) A service plan must include the recipient’s signature agreeing to the plan and  
state when updates are made.  
COMMENT – It is not possible to have a completed service plan done within 24 hours of  
admission, especially for residential and residential withdrawal management programs.  
Often the full biopsychosocial assessment is not completed within 24 hours of  
admission to a withdrawal management program. Also, proposed timeframes do not  
account for weekends or holidays. This is unrealistic and providers will not be able to  
comply. Additionally, to require this from an opioid treatment program within 24 hours of  
admission will cause delays in people receiving services. Programs will schedule  
individuals for their initial appointment with a physician often times without having a  
therapist available to conduct the assessment and complete a treatment plan the same  
day. Having an individual get started on his/her medication is a harm reduction strategy  
and is often utilized prior to a full biopsychosocial assessment being completed to not  
delay the admission.  
R 325.1377 Community change, alternatives, information, and training (CAIT).  
Rescinded.  
R 325.1379 Screening and assessment, referral, follow-up (SARF) services;  
requirements. Rescinded.  
Page 2 of 5  
COMMENT – Agree with eliminating these sections  
R 325.1381 Outpatient counselingservices; program requirements.  
Rule 1381.  
(6) A licensee shall ensure that a limited certified counselor in not responsible for  
more than 32 recipients.  
COMMENTS – (6) – What information was used to determine that a limited certified  
counselor cannot be responsible for more than 32 recipients. The amount of services  
needed by each recipient is individualized. Additionally, organizations look at full time  
positions the same regardless of an individual’s credentials. Limited certified  
counselors should not be forced to have a reduced case size.  
R 325.1383 Medication assisted treatment (MAT) services; Methadone program  
requirements.  
(6) A licensee shall ensure that a limited certified counselor in not responsible for  
more than 32 recipients.  
(12) A licensee shall comply with all requirements set forth in 42 CFR § 8.  
(6) What information was used to determine that a limited certified counselor cannot be  
responsible for more than 32 recipients? The number of services needed by each  
recipient is individualized and different. Additionally, organizations look at full time  
positions the same regardless of an individual’s credentials. Limited certified  
counselors should not be forced to have a reduced case size.  
(12) Support this change  
R 325.1385 Residential program services; requirements.  
(5) A licensee shall ensure that a limited certified counselor is not responsible for  
more than 10 recipients.  
(58) A licensee shall provide and ensure recipient participation in at least not less than  
15 hours per week of treatment and support and rehabilitation services to meet the  
needs of the recipients to take place days, evenings, and weekends. Not less than At  
least 310 of the 15 hours must be treatment in the form of treatment or rehabilitation  
evidence-based practice or services individual counseling, group counseling, social  
skills training, cognitive behavioral therapy, motivational interviewing, couples  
counseling, or family counseling for each recipient. Participation shall must be  
documented in the recipient record.  
COMMENTS –  
(5) What information was used to determine that a limited certified counselor cannot be  
responsible for more than 10 recipients. Additionally, organizations look at full time  
positions the same regardless of an individual’s credentials. Limited certified  
counselors should not be forced to have a reduced case size.  
Page 3 of 5  
(8) The hours per week requirement goes above what is required by the American  
Society of Addiction Medicine for ASAM Residential Level III.1 and what is required by  
the MDHHS.  
R 325.1388 Residential Withdrawal management program requirements.  
Rule 1388.  
(2) A program offering clinically managed withdrawal management services offers  
peer and social support services only and not offer or administer schedule II-V  
controlled substances for the management of withdrawal, including methadone  
and buprenorphine.  
(4) A residential withdrawal management program shall meet all of the following  
requirements:  
(c) A physician, physician’s assistant, or advanced practice registered nurse shall  
review and assess each recipient upon admission and every 72 hours after the  
initial review and assessment to determine if the recipient is suitable for the  
services being offered. If a recipient is referred from a licensed acute care  
hospital, psychiatric unit, or hospital directly to a licensed residential withdrawal  
management program, the transfer documentation, including the health  
assessment from the transferring hospital, may be used as the initial assessment  
for admission if all of the following are met:  
(6) A residential withdrawal management program offering medically monitored  
withdrawal management services must also meet both of the following  
requirements:  
(a) A licensee shall have a physician, physician’s assistant, or advanced practice  
registered nurse complete and document the medical and drug history, as well as  
a physical examination of the recipient, before administering any medications. In  
addition, any modification to medications or course of treatment must be  
documented in the recipient record and ordered by a physician, physician’s  
assistant, or advanced practice registered nurse.  
COMMENTS - (2) Why are clinically managed withdrawal management programs not  
allowed to utilize medications that are allowed to be prescribed by primary care offices?  
(4)(c) Requiring a physician, physician’s assistant, or advanced practice registered  
nurse to review and assess each recipient upon admission is exceeding the level of  
medical care required by the American Society of Addiction Medicine for this level of  
care. As stated in the ASAM Criteria, a physician (or physician extender) should be  
“available to assess the patient within 24 hours of admission.” ASAM Criteria states, a  
registered nurse or other licensed and credentialed nurse is available to conduct a  
nursing assessment on admission. This requirement forces providers to limit  
admissions to those hours a physician or mid-level is available which impacts access to  
services and is not a national requirement. Individuals scheduled for admission into this  
level of care rarely arrive at their scheduled appointment time. Providers do not turn  
someone away who misses his/her appointment, but typically do not have physicians  
and/or mid-levels available to complete an initial assessment at the time of admission  
which could be 24 hours per day.  
Page 4 of 5  
6(a) Requiring physical examinations prior to administering any medication exceeds the  
level of medical care necessary for this level of treatment. As stated in ASAM Criteria, a  
physician (or physician extender) should be “available to assess the patient within 24  
hours of admission.” ASAM Criteria states, a registered nurse or other licensed and  
credentialed nurse is available to conduct a nursing assessment on admission. This  
requirement forces providers to limit admissions to those hours a physician or mid-level  
is available which impacts access to services and is not a national requirement.  
Individuals scheduled for admission into this level of care rarely arrive at their scheduled  
appointment time. Providers do not turn someone away who misses his/her  
appointment, but typically do not have physicians and/or mid-levels available to  
complete an initial assessment at the time of admission which could be 24 hours per  
day.  
R 325.1391 Recipient rights.  
R 325.1393 Treatment Service plan; specific recipient rights.  
(3) Unless notified in writing before admission, a recipient may utilize  
medications as prescribed by a physician.  
COMMENTS – This is a liability to the provider. A provider is not always made aware of  
prescribed medications at the time of admission if the individual does not present with  
the medication or indicate all prescribed medications in the outpatient level of care,  
especially medication assisted treatment. Additionally, medications can be prescribed  
after admitted to a program. The proposed language would restrict a program from  
safely managing care.  
Again, thank you for the opportunity to provide feedback and for the changes that were  
previously made. Sacred Heart is supportive of the majority of the changes proposed by  
LARA. The feedback/concerns highlighted above promote the health and safety of  
individuals in our care, further improve the delivery of services within our system and  
create consistency between the licensing rules and the American Society of Addiction  
Medicine Patient Placement Criteria. I can be reached at 810-392-2167, Extension  
1303, or electronically at pnelson@sacredheartcenter.com.  
Sincerely,  
Paula Nelson, President and CEO  
Page 5 of 5  
Bagby, Tammy (LARA)  
From:  
Sent:  
To:  
Kanzoni Asabigi <kasabigi@recovery4detroit.com>  
Wednesday, August 31, 2022 12:52 PM  
LARA-BCHS-Training  
Subject:  
Proposed SUD Rule Changes - Rule Set 2021-90LR  
CAUTION: This is an External email. Please send suspicious emails to abuse@michigan.gov  
Hello:  
Thank you for allowing me to make a presentation at the hearing this  
morning. Below is a written summary of the feedback.  
Positive Highlights:  
• Eliminating barriers to buprenorphine—the draft rules would eliminate  
the additional state licensure  
requirement related to the provision of buprenorphine. This change  
removes a potential barrier to expanded  
care across the state (e.g., proposed strike of Rule 325.1303(3)(c)). The  
proposed rules also require licensees to  
facilitate access to MOUD if desired by a recipient (proposed Rule  
325.1331(2)(c)).  
• Authorization of mobile and branch units—the draft rules authorize  
branch and mobile units, which will help  
increase access to care in underserved areas of the state (proposed Rule  
325.1304).  
• Promoting naloxone access—the proposed rules require programs to  
offer naloxone kits to recipients at high  
risk of overdose, a key overdose prevention strategy (proposed Rule  
325.1331(2)(f)).  
• Aligning methadone standards with federal law—the proposed rules  
more closely align Michigan’s  
requirements for Opioid Treatment Programs with federal law (i.e.,  
around frequency of drug testing and  
1
requirements for takehomes) (proposed Rule 325.1383(12) and strike of  
Rules 325.1383(14) and (15)).  
• Discouraging discharge solely for return to use: under the proposed  
rules, a licensee’s policies and procedures  
may not allow a person’s discharge from a program due to a return to use  
as long as the person reengages in  
treatment and complies with program requirements (proposed  
325.1331(2)(e)).  
Thank you.  
--  
Kanzoni Asabigi, MD, PhD, MPH  
Vice President  
Detroit Recovery Project, Inc  
1145 W. Grand Blvd  
Detroit MI 48208  
Tel: 313-324-8900 ext 1302  
Fax: 313-263-0281  
Confidentiality Note:  
The above information is intended for the addressee and may contain information that is privileged, confidential, or  
otherwise exempt from disclosure under applicable law. If the reader of this message is not the intended recipient or the  
employee or agent responsible for delivering the message to the intended recipient, you are hereby notified that any  
dissemination, distribution, or copying of this communication is strictly prohibited. If you have received this  
communication in error, please immediately notify us by telephone at the above number. Thank you.  
2
Bagby, Tammy (LARA)  
From:  
Sent:  
To:  
Emmy Ellis <EEllis@arborcircle.org>  
Wednesday, August 31, 2022 1:35 PM  
LARA-BCHS-Training  
Subject:  
Licensing rules - public comment  
CAUTION: This is an External email. Please send suspicious emails to abuse@michigan.gov  
Hello,  
Thank-you for the opportunity to offer public comment regarding the proposed changes to the SA licensing rules. Please  
accept my comments below for official public comment regarding the proposed changes to the Substance Use Disorder  
Service Programs rule set.  
Regarding prevention:  
While the content, model and structure of substance use disorder prevention programs could look to the outside as a  
low risk activity, the reality is that prevention programs and services across the State of Michigan are often interacting  
with our most vulnerable populations; children and youth. Prevention providers are going into schools, providing after-  
school programming, holding groups with youth at risk for a variety of concerns like homelessness, abuse and neglect,  
early use of alcohol and other drugs, mental illness and more. Prevention providers also provide services convening  
community members, educating parents, and many more activities. While it may seem like these are low risk activities  
with few safety concerns, removing the CAIT license completely would remove the requirements for agencies providing  
these services to ensure proper staff licensure, proper staff training, proper safety monitoring and safety practices, and  
could impact ethical practice. While an individual staff licensure could ensure individual ethical practice, licensing an  
organization ensures that all prevention practices have a minimum standard of excellence in caring for our most  
vulnerable.  
Regarding Treatment:  
Under Part II R 325.1303, it is stated that a license is not required for an individual offering  
psychological medical or social services within the scope of his or her individual professional  
license and not under a group or organization offering substance use disorder services.” Can  
you clarify if appropriately licensed clinicians can provide SUD treatment (other than  
methadone tx) in a private practice?  
Under Part 2 Subpart A, R 325.1304, the branch location hours are limiting at 20 hours. There are  
opportunities for clinicians to provide more than 20 hours at a separate location especially in more rural  
areas. However, the sites would never have the need for a fully licensed office. I would like you to  
consider increasing the hours from 20 to 32 hours in order to accommodate the needs in these  
communities.  
“Under Subpart D R 325.1363, completion of an individualized treatment plan at the next session  
is not always feasible. The newly State of MI required ASAM Continuum can take 2 sessions to  
complete. Additionally, people often need more time to fully engage. Recovery is a strain  
emotionally and physically, sharing this and translating it into a meaningful plan takes longer  
than one session. I would suggest 3 sessions or 30 days, whichever comes first.  
1
Thank-you again for the opportunity to provide input.  
Emmy Ellis LMSW  
She/Her pronouns  
Program Manager, Outpatient Counseling Services  
Arbor Circle  
Strong relationships. Resilient people.  
1115 Ball Ave. NE  
Grand Rapids, MI 49505  
Office Ph: 616-459-7215  
Cell: 616-498-8182  
F: 616-451-0020  
www.arborcircle.org  
2
August 31, 2022  
Tammy Bagby  
Department of Licensing and Regulatory Affairs  
Bureau of Community and Health Systems  
PO Box 30664, Lansing, MI 48909  
Via Electronic Submission  
Re: Administrative Rules for Substance Use Disorder Service Programs Rule Set 2021-90 LR  
Dear Ms. Bagby:  
BHSH System appreciates the opportunity to provide comments on the Administrative Rules for  
Substance Use Disorder Service Programs Rule Set 2021-90 LR. Formed on February 1, 2022 from two  
leading health systems in Michigan (Beaumont Health and Spectrum Health), BHSH System is a not-for-  
profit health system that provides care and coverage with an exceptional team of 64,000+ dedicated team  
members—including more than 11,500 physicians and advanced practice providers and more than  
15,000 nurses offering services in 22 hospitals, 300+ outpatient locations and several post-acute  
facilities—and Priority Health, a provider-sponsored health plan serving over 1.2 million members across  
the state of Michigan. We are boldly creating a future where health is simple, affordable, equitable and  
exceptional. It is from the perspective of an integrated health system that we offer the following  
comments.  
As an organization we are committed to providing low barrier access to high quality substance use  
treatment. Therefore, our substance use providers and our organization as a whole is in strong  
agreement with the proposed administrative changes.  
These proposed rule changes will help better differentiate the levels of care available at an outpatient  
buprenorphine and naltrexone office versus a methadone treatment program. Often patients who have  
more serve disease and need closer monitoring are followed by a methadone clinic. However, patients  
with less serve disease, or those further along in treatment may not need this level of strict monitoring. It  
may in fact be a hinderance to patients being able to continue in care. Therefore, by decreasing the  
number of urine drug screens required during one year, and by expanding and modifying rules related to  
outpatient buprenorphine and naltrexone clinics, we will be able to better care for our patients and  
improve access to treatment.  
We also believe that the adoption of the proposed mobile health rules will allow our provider team  
to expand our reach to some of the highest risk and most underserved patients. The lessons  
learned from the COVID-19 pandemic have showed that the use of mobile health and telehealth are  
essential tools to provide equitable and quality substance use care to our rural communities. With that  
said, BHSH System believes that if a parent organization has the staffing, resources, and  
community demand to provide more than three mobile units, then they should be allowed to do  
so.  
In addition, removing the x-waiver requirement is essential. The x-waiver requirement is a barrier  
that often times prevents pain medicine specialists or other medical providers from feeling  
comfortable prescribing buprenorphine. This is an unnecessary barrier that prevents patients from  
accessing a safe treatment option for chronic pain and prevents medical providers from providing MAT to  
patients with opioid use disorder.  
100 Michigan Street NE | MC60 | Grand Rapids, MI 49503  
26901 Beaumont Boulevard | Southfield, MI 48033  
We also strongly support of the proposed changes to expand to behavioral health support. We are also  
in strong support of increasing the recipient-to-counselor ratio and allowing limited certified  
counselors to provider behavioral health support. This proposed change will have an immediate  
improvement on access to behavioral health support for our patient population. Implementing a similar  
model to Wisconsin’s SUD 1 to 50 limited certified counselor-to-recipient ratio would be even  
more beneficial for the residents of Michigan.  
Overall, it is our view that the spirit of the proposed regulations supports the de-stigmatizing of substance  
use treatment and to minimize the risks of harm in those patients using substances. This is aligned with  
harm reduction and the best evidence-based approach to substance use treatment.  
Thank you for your consideration of our comments,  
Colleen Lane  
Addiction Medical Director  
Spectrum Health West Michigan  
100 Michigan Street NE | MC60 | Grand Rapids, MI 49503  
26901 Beaumont Boulevard | Southfield, MI 48033  
August 31, 2022  
Bureau of Community and Health Systems  
Attn: Tammy Bagby  
PO Box 30664,  
Lansing, MI 48909  
Bureau of Community and Health Systems:  
The intent of this letter is to seek clarification on a current ruleset on the Substance Use Disorders  
Service Program. This information would benefit the JCAR Committee before it is submitted.  
The rule states:  
R 325.1388 Residential withdrawal management program requirements.  
Rule 1388. (1) Residential withdrawal management programs must be based on a documented  
assessment of the recipient's needs and a subsequent agreement between the recipient and the  
provider about the services to be offered.  
(2) A program offering clinically managed withdrawal management services shall offer peer and  
social support services only and not offer or administer schedule II-V controlled substances, as  
classified under 21 USC 812, for the management of withdrawal, including methadone and  
buprenorphine.  
(3) A program offering medically monitored withdrawal management services shall offer medical  
and nursing care and may administer medications for the management of withdrawal.  
We were contacted by the Provider Alliance, a trade association for SUD providers including some  
of our constituents. They are concerned about the language in R325.1388(2). It states “A program  
offering clinically managed withdrawal management services (also known as social detox) shall  
offer….and not offer or administer schedule II-V controlled substances, as classified under 21 USC  
812, for the management of withdrawal, including methadone and buprenorphine….” (p. 22)  
We are looking for assurance from LARA that the interpretation and enforcement of the language  
around controlled substances would allow programs to supervise an individual self-administering  
medication including controlled substances used to manage withdrawal symptoms. This is with the  
understanding that the medications are labeled, dispensed prescriptions in bottles with the  
individual’s name on them from an independent pharmacy.  
This practice would be in line with state and federal program standards for Clinically Managed  
Withdrawal Management (ASAM Level 3.2) which all allow for the supervision of a person taking of  
their own prescribed medication in this level of programming. This includes:  
•
•
•
MDHHS/Michigan Medicaid Program Standards, Treatment Policy 13, p.6 (LINK)  
American Society for Addiction Medicine (ASAM), p.43 (LINK)  
U.S. Substance Abuse Mental Health Service Administration (SAMHSA),  
Detoxification and Substance Abuse Treatment, Treatment Improvement Protocol  
#45 (LINK)  
•
Carf (Commision on Accreditation of Rehabilitation Facilities) 2022 Behavioral Health  
Standards Manual, Section 2.e.2  
This interpretation and application of R325.1388(2), to allow the supervision of self-administration,  
would be critical to allow for individuals who are directly transferred from a licensed acute care,  
psychiatric unit, or hospital as referenced in R325.1388(4). Many of these individuals may leave that  
facility with prescribed medications to manage their symptoms. These medications would be  
labelled and dispensed by an independent pharmacy.  
Thank you for taking the time to read this letter. In order for us to move forward in confidence with  
the JCAR process, we are requesting a written response clarifying how LARA would be interpreting,  
applying and enforcing this specific standard. This will inform the committee how it would need to  
act when the proposed ruleset comes to us. As you know if the legislature proposes that the rule be  
changed, the agency or department can either make the decision to change the rule, and within 30  
days resubmit the rule to the committee or make the decision to not change the rule and notify the  
committee.  
Sincerely,  
Luke Meerman  
State Representative  
88th District  
Ed McBroom  
State Senator  
38th District  
Bumstead  
State Senator  
34th District  
CC: “Katherine Wienczewski, Administrative Rules Manager, Michigan Office of Administrative  
Hearings and Rules”.  
;