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Authors Posts by Jason Snyder

Jason Snyder

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The Pennsylvania Department of Drug and Alcohol Programs (DDAP) will host a webinar at 10:00 am on Monday, March 3, to discuss the changes to 42 CFR Part 8 and their real-world implications in treatment settings. The interactive session will feature Dr. Sarah Kawasaki and Elizabeth Ward, both from the Pennsylvania Psychiatric Institute’s Advancement in Recovery Opioid Treatment Program.

Add the meeting to your calendar.

Email DDAP to receive calendar invitations to upcoming webinars, which are held the first Monday of every month.

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The Commission on Accreditation of Rehabilitation Facilities (CARF) recently convened an International Standards Advisory Committee (ISAC) to develop new accreditation standards for an Integrated Primary Care specialty designation. A specialty designation requires a program seeking accreditation to meet an additional set of standards that reflects its expertise in a specific type of service delivery or for a specific population of persons served. Integrating primary care into a mental health or substance use disorder program allows the program to holistically address the behavioral health, physical health, and social needs of the persons served, enhance the level of care provided, and improve outcomes for the persons served. Through the efforts of the ISAC, the program standards for Health Home were also updated. The final standards will be published in CARF’s 2026 standards manuals for Behavioral Health, Child and Youth Services, and Opioid Treatment Programs.

CARF is seeking comments on each of the proposed descriptions and standards. The deadline to submit comments is Tuesday, February 25.

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As I watched Pennsylvania Governor Josh Shapiro give his budget address last Tuesday, it occurred to me that the light Pennsylvania government had brightly shined on the addiction epidemic for nearly the past 10 years has greatly dimmed.

In a speech of nearly 11,000 words, not one of them was “addiction.” Not one mention of treatment. No mention at all of an overdose death epidemic. Over the course of a 90-minute budget address, Gov. Shapiro, a man who likes to “get stuff done,” did not even attempt to take credit for overdose death numbers that are trending downward. He didn’t acknowledge them at all.

Granted, the Pennsylvania Department of Drug and Alcohol Programs (DDAP) continues to release pots of opioid settlement and federal money, including State Opioid Response (SOR) funding, into the behavioral health ecosystem, though not all of it is available to DDAP-licensed treatment providers. Counties also continue to spend opioid settlement dollars from multiple sources, including a national settlement with the three largest pharmaceutical distributors that netted more than $1 billion for Pennsylvania.

In arguing that everyone else is legalizing adult-use recreational marijuana, so Pennsylvania should, too, the governor ignores the evidence of the harms of marijuana, including a link between legalized adult recreational marijuana and an increase in adolescent suicides, as well as the broader implications for addiction treatment such that not one dime of the $536,000,000 in estimated Fiscal Year 2025/26 revenue is proposed to be directly allocated to DDAP. Although it appears recreational legalization is inevitable at some point, failing to acknowledge its potential to harm some Pennsylvanians is disingenuous.

Dig a little deeper into the budget, and it looks no brighter for addiction treatment providers.

Behavioral HealthChoices — the name for Pennsylvania’s Medicaid managed care program for behavioral health — currently is in a financial crisis. Pennsylvania counties and behavioral health managed care organizations (BH-MCO) are reporting to be significantly underfunded due to a Department of Human Services’ (DHS) actuarial error made in calculating the effects of the unwind of the Medicaid rolls post-Covid. The underfunding is affecting the counties’ abilities to meet contractual obligations to provide behavioral health services. In other words, the $6.3 billion comprised of state and federal dollars in the current fiscal year (2024/25) budget (see p. 104 of 372 of DHS’s budget book) for Behavioral HealthChoices capitation — capitation being a form of payment based on a complex formula that determines an amount of money needed per Medicaid recipient per month — is not enough money to pay for addiction and mental health treatment for everyone who wants and needs it.

Although we see an 18 percent increase in the HealthChoices capitation line item that amounts to $660 million in state dollars in the governor’s proposed executive budget, significant questions are still unanswered and even bigger concerns remain.

For example, we do not know how much of the 18 percent increase is earmarked for Behavioral HealthChoices, which is concerning because the Physical HealthChoices program also is underfunded, and the Physical HealthChoices program is a significantly higher expenditure. Estimates suggest that the Behavioral and Physical HealthChoices systems combined need an additional $2.5 billion (state and federal combined) in the current calendar year, which is partly funded by two separate fiscal year budgets, to meet their obligations to Pennsylvania’s most vulnerable. There is a $230,000,000 supplemental payment in the proposed budget, which would help to address the immediate need for additional funds in the current fiscal year, but we are hearing only a small percentage of this is for the HealthChoices issue.

As a result of the underfunding and uncertainty, BH-MCOs and primary contractors have announced to addiction and mental health treatment providers that they will not receive any increases in reimbursement rates in 2025, despite escalating provider costs. At the same time, in certain regions of the Commonwealth, addiction and mental health treatment providers are beginning to report increasing challenges in getting appropriate treatment authorized (e.g., decreased lengths of stay, increased denials). Although anecdotal, RCPA will continue to have these discussions and look to substantiating data.

The current HealthChoices crisis has been building since early 2024 and has caused much anxiety. So far, the proposed 2025/26 budget only exacerbates the worry. Add in the federal Medicaid and grant funding uncertainty coming out of Washington, DC following recent executive orders that potentially put funding streams like the Substance Use Prevention, Treatment, and Recovery Services Block Grant and SOR dollars at risk, and the calamity grows exponentially. Right now, we are looking at a real possibility of ongoing behavioral health service cuts that would be akin to rationing of care.

At this point, I am left with a few fundamental questions. How is $6.3 billion not enough to provide behavioral health services — addiction and mental health treatment — to Pennsylvania’s Medicaid population? How could the state have been so wrong on its calculations? How sustainable is a behavioral health system that needs at least upwards of $7 billion per year? Does the legislature have an appetite for such a system?

And, perhaps most importantly, what are the implications for the future of addiction treatment and the sustainability of the system as we currently know it? Beyond the funding crisis, the field continues to beg for relief from administrative burden and crushing oversight, pleas that have amounted to shouting into the void.

With DHS’s budget hearings coming up in early March in front of the Senate and House Appropriations Committees, I would expect the legislature to also be asking these same questions. Stay tuned.

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Photo by CHUTTERSNAP on Unsplash

Registration for the Pennsylvania Commission on Crime and Delinquency’s (PCCD) 2025 Criminal Justice Advisory Board (CJAB) Conference is now open. The conference, “From Crisis to Collaboration: Building Resilient Justice Systems,” will be held on April 22–23, 2025, at the Penn Stater Hotel and Conference Center in State College. This year’s event will bring together criminal justice, behavioral health, and treatment partners, including national and local experts who will discuss new and emerging issues affecting the justice and behavioral health systems, providing innovative strategies and collaborative solutions to meet the challenges ahead.

To register for the conference and to view the agendas and session descriptions, visit the 2025 CJAB Conference page on PCCD’s website.

The deadline to register for the conference is Friday, March 28. The deadline for the discounted room rate of $139 is Friday, March 21. There is no fee to attend the conference.

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Earlier this month the Drug Enforcement Agency (DEA) issued a Notice of Proposed Rulemaking (NPRM) for Special Registrations for Telemedicine and Limited State Telemedicine Registrations. DEA is seeking public comment by March 18, 2025.

RCPA is considering whether it will submit comments. If you have comments about the proposed rule that you would like to make part of any RCPA response or if you would like to discuss the proposed rule, please contact RCPA SUD Treatment Services Policy Director Jason Snyder.

The NPRM introduces three types of Special Registrations for Telemedicine:

  1. A Telemedicine Prescribing Registration, authorizing qualified clinician practitioners to prescribe Schedule III-V controlled substances via telemedicine;
  2. An Advanced Telemedicine Prescribing Registration, authorizing qualified, specialized clinician practitioners (i.e., psychiatrists, hospice care physicians, physicians rendering treatment at long-term care facilities, and pediatricians for the prescribing of medications identified as the most addictive and prone to diversion to the illegal drug market) to prescribe Schedule II-V controlled substances via telemedicine; and
  3. A Telemedicine Platform Registration, authorizing covered online telemedicine platforms, in their capacity as platform practitioners, to dispense Schedule II-V controlled substances. To satisfy the statutory requirements, DEA would also require the special registrant to maintain a State Telemedicine Registration for every state in which a patient is treated by the special registrant, unless otherwise exempted. The State Telemedicine Registration would be issued by DEA, not the states, and operate as an ancillary credential, contingent on the Special Registration held by the special registrant.

Public comments are also requested on additional patient protections for the prescribing of Schedule II medications by telemedicine, including:

  • Whether the special registrant should be physically located in the same state as the patient being prescribed Schedule II medications;
  • Whether to limit Schedule II medications by telemedicine to medical practitioners whose practice is limited to less than 50 percent of prescriptions by telemedicine; and
  • The appropriate duration needed for the rules’ provisions to be enacted.

The special registration rule will also require the establishment of a national prescription drug monitoring program (PDMP) to help the health industry protect against abuse and the diversion of controlled substances into the illegal drug market. A national PDMP will provide pharmacists and medical practitioners with visibility of a patient’s prescribed medication history.

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The Pennsylvania Department of Drug and Alcohol Programs (DDAP) is hosting two upcoming Clinical Supervision Trainings (CST). These in-person trainings will build on the information provided in the online training and provide participants with the opportunity to practice their clinical supervision skills. Participants will also be provided with tools to assist in assessing and working with their supervisees.

The in-person trainings are being held at:

  • Allegheny County Single County Authority, 1 Smithfield St, Pittsburgh
    Monday, March 17 – Friday, March 21
  • Pine Barn Inn, 43 Pine Barn Pl, Danville
    Monday, April 21 – Friday, April 25

Trainings are from 9:00 am – 4:00 pm each day, and there is a $300 fee to attend. Registration is limited and will be processed in the order registrations are received. Those interested in the training can register on the Training Management System website. Email DDAP’s Training inbox with any questions.

The remainder of the 2025 CST dates and regions are listed below. Once locations are confirmed, they will be updated in DDAP’s Training Management System (TMS), offering a variety of in-person and virtual training to maintain your skills and fulfill requirements.

  • Southeast Region: Monday, May 12 – Friday, May 16
  • Northwest Region: Monday, June 9 – Friday, June 13
  • Northeast Region: Monday, August 25 – Friday, August 29
  • Southcentral Region: Monday, September 15 – Friday, September 19
  • Southwest Region: Monday, October 27 – Friday, October 31
  • Southeast Region: Monday, November 3 – Friday, November 7

DDAP has approved additional options for completing this requirement for those unable to attend an event but in need of training to fulfill licensing regulation requirements.

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The Erie Coalition for a Trauma-Informed Community (ECTIC) is hosting its Resilience Conference on Wednesday, February 19. The conference theme, “Back to Basics: Moving Policy and Practice Forward,” emphasizes returning to foundational principles to create meaningful change. By focusing on practical strategies and actionable insights, the conference aims to empower individuals and organizations to advance trauma-informed policies and practices that foster resilience across our communities.

The daylong virtual conference is free. Conference registration, session information, and other details are available online.

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Separate Notice of Proposed Rulemaking Would Completely Eliminate In-Person Evaluation for Prescribed Medications

The Substance Abuse and Mental Health Services Administration (SAMHSA) and the U.S. Drug Enforcement Agency (DEA) this month released three new prescribing-related telehealth rules.

The Final Rule On the Expansion of Buprenorphine Treatment Via Telemedicine Encounter authorizes DEA-registered practitioners to prescribe Schedule III-V controlled substances, including buprenorphine, for opioid use disorder, through an audio-only encounter for an initial six-month supply (split among multiple prescriptions over six calendar months). Although the rule has been published in the Federal Register and is set to take effect February 18, 2025, President Trump issued a regulatory freeze pending review that requires executive departments and agencies to consider postponing the rule’s effective date for 60 days to review “any questions of fact, law, and policy that the rules may raise.”

Under this final rule, practitioners must first review the patient’s prescription drug monitoring program data for the state in which the patient is located during the telemedicine encounter. Additional prescriptions can be issued under other forms of telemedicine as authorized under the Controlled Substances Act, or after an in-person medical evaluation is conducted. SAMHSA advises practitioners to check with their state medical boards about what specific telemedicine practices are currently authorized for prescribing controlled medications after this six-month period. RCPA has reached out to the Pennsylvania Department of State to determine whether there are telemedicine pathways in place to enable prescribing beyond the initial six-month period without an in-person examination.

This regulation also requires the pharmacist to verify the identity of the patient prior to filling a prescription. This final rule does not apply to practitioners who have already evaluated their patient in person.

Separate Proposed Rule Would Completely Eliminate In-Person Evaluation for Prescribed Medications

However, a separate proposed rule on Special Registrations for Telemedicine and Limited State Telemedicine Registrations would establish special registrations that will permit a patient to receive prescribed medications through telemedicine visits without ever having an in-person medical evaluation from a medical provider. According to the DEA, the special registration is available to medical providers who treat patients for whom they will prescribe Schedule III-V controlled substances. An Advanced Telemedicine Prescribing Registration is available for Schedule II medications when the medical practitioner is board certified in one of the following specialties: psychiatrists; hospice care physicians; physicians rendering treatment at long term care facilities; and pediatricians for the prescribing of medications identified as the most addictive and prone to diversion to the illegal drug market. This regulation allows specialized medical providers to issue telemedicine prescriptions for Schedule II-V medications.

DEA is seeking public comment by March 18, 2025, on additional medical specialists that should be authorized to issue Schedule II medications. Public comments will also be requested on additional patient protections for the prescribing of Schedule II medications by telemedicine, including whether the special registrant should be physically located in the same state as the patient being prescribed Schedule II medications; whether to limit Schedule II medications by telemedicine to medical practitioners whose practice is limited to less than 50 percent of prescriptions by telemedicine; and the appropriate duration needed for the rules’ provisions to be enacted.

For the first time, online platforms that facilitate connections between patients and medical providers that result in the prescription of medications will be required to register with DEA. This is critical, as DEA has found some unscrupulous medical providers on online platforms have used flexible telemedicine rules to put profit ahead of the well-being of patients.

The special registration rule will also require the establishment of a national PDMP to help the health industry protect against abuse and the diversion of controlled substances into the illegal drug market. A national PDMP will provide pharmacists and medical practitioners with visibility of a patient’s prescribed medication history.

Additionally, a Final Rule on Continuity of Care Via Telemedicine for Veterans Affairs (VA) patients was issued, allowing practitioners acting within the scope of their VA employment to prescribe controlled substances via telemedicine to a VA patient with whom they have not conducted an in-person medical evaluation. VA practitioners are permitted to prescribe controlled substances to VA patients if another VA practitioner has, at any time, previously conducted an in-person medical evaluation of the VA patient, subject to certain conditions.

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If they haven’t already, very few people seeking addiction treatment will ever experience it as Tom Coderre did.

Coderre is principal deputy assistant secretary for the Substance Abuse and Mental Health Services Administration (SAMHSA). Last week, in kicking off its inaugural Substance Use Disorder Treatment Month, SAMHSA published a blog in which Coderre’s treatment story was retold.

“I started treatment at the end of May 2003, after an arrest for possession of a controlled substance, when a compassionate judge strongly suggested it,” the former Rhode Island state senator said. “The treatment program offered flexible lengths of stay, determined on an individual basis … For me, that treatment episode lasted five and a half months and I then transitioned into a recovery house.”

You read that correctly. Five-and-a-half months. Not five-and-a-half-months in the continuum of residential to halfway house to partial hospitalization to intensive outpatient to outpatient, but five-and-a-half months in an intensive residential treatment center before transitioning to a recovery house. And keep in mind, Coderre’s treatment was funded by a federal block grant, not out of pocket or through commercial insurance.

Coderre’s story truly is remarkable. He gave a great interview to William White in 2016 that details his story and demonstrates the power of treatment and recovery. But to hold up this treatment experience in a blog that kicks off national SUD Treatment Month is to suggest, in my read, that this is what addiction treatment could look like today. And, barring some very specific and unique cases, that is simply not true, and certainly not in Pennsylvania.

Imagine a person with the disease of addiction desperately in need of treatment who is assessed as: being unable to control impulses; having marked difficulty with or opposition to treatment, with dangerous consequences; having no recognition of the skills needed to prevent continued use, with imminently dangerous consequences; and lacking skills to cope outside of a highly structured 24-hour setting.

That is essentially the definition of someone needing ASAM Level 3.5, which is defined as clinically managed, high-intensity residential treatment.

Anecdotal information tells us the average length of stay in Pennsylvania at Level 3.5, including withdrawal management (which we used to call detox), is about 28 days. Lower intensity treatment, such as that provided at Level 3.1 (i.e., halfway houses), can garner as much as a five-month stay, at about $100 less per day in Medicaid reimbursement than Level 3.5.

Much has changed about the way we treat addiction since Coderre’s treatment experience nearly 22 years ago. And we would expect the field to change and evolve, just as we would hope cancer is not being treated today the same way it was 25 years ago.

Many will argue that there is not enough evidence to support such a time- and cost-intensive treatment approach as longer-term, high-intensity residential treatment. Many will argue, too, that outcomes are just as effective with medication or intensive outpatient. Just as many will argue the other side of the coin, that 14- and 21- and 28-day lengths of stay are not enough time to stabilize and begin the hard work necessary to rehabilitate (and often times habilitate) someone whose “addiction is currently so out of control that they need a 24-hour supportive treatment environment … ” (ASAM Third Edition, 2003).

What isn’t up for debate is the sea change taking place in addiction treatment today.

It’s difficult to find a current definition or purpose of addiction treatment today, even from SAMHSA or the National Institute on Drug Abuse (NIDA). But Nora Volkow, director of NIDA, wrote in 2022 that, “The magnitude of this [drug overdose death] crisis demands out-of-the-box thinking and willingness to jettison old, unhelpful, and unsupported assumptions about what treatment and recovery need to look like. Among them is the traditional view that abstinence is the sole aim and only valid outcome of addiction treatment.”

Only 10 years prior, NIDA wrote in its Principles of Drug Addiction Treatment that, “In addition to stopping drug abuse, the goal of treatment is to return people to productive functioning in the family, workplace, and community.”

And SAMHSA’s Center for Substance Abuse Treatment, 20 years ago, was even clearer on the purpose of treatment: “Treatment for substance use disorders is designed to help people stop alcohol or drug use and remain sober and drug free. Recovery is a lifelong process.”

From stopping alcohol or drug use and remaining sober and drug free, to stopping drug abuse, to jettisoning old, unhelpful assumptions that the sole aim and only valid outcome of addiction treatment is abstinence – that is a sea change.

Today, treatment for addiction is not about abstinence, at least to federal and state government regulators and payers. Consider SAMHSA’s definition of recovery: “a process of change through which individuals improve their health and wellness; live a self-directed life; and strive to reach their full potential.” Millions of people subscribe to that definition, which does not include abstinence.

Additionally, to me, it also seems clear that what has historically been the cornerstone of the addiction treatment system – in Pennsylvania, all of the Department of Drug and Alcohol Program (DDAP)-licensed providers comprising all of the ASAM levels of care – is no longer viewed in the same way.

Physical health providers that treat with medicine and do not have a DDAP license are becoming central to treating addiction. To wit, DDAP recently issued a funding opportunity for “Integrated Health Solutions between Behavioral Health Care and Primary Physical Health Care.” DDAP-licensed providers cannot apply for the funding. Other recent funding opportunities, for harm reduction and recovery support, for example, also are not open to licensed treatment providers.

Harm reduction, recovery support, and crisis and drop-in centers are all being recognized as viable components of an evolving system. And certainly they are less costly than long-term treatment. The question is, “How effective are they compared to traditional forms of treatment?” Depends who you ask.

Call it a no-wrong-door approach, meeting people where they’re at, removing siloes, integration or coordination, but addiction treatment “proper” is no longer the center of addiction treatment.

I am not arguing that this expansion and evolution is wrong or misdirected. I would ask a few questions, though. How will “traditional” treatment providers react and evolve in response? And how adequately are regulators and payers supporting them in any transitions they expect to see? Do providers even feel they need to evolve away from their core mission? It would be interesting to get Coderre’s thoughts about this, as well as how he thinks he or someone with addiction as severe as his would fare in today’s treatment environment.

Tom, if you’re reading, we would be grateful for an opportunity to talk.

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The Pennsylvania Department of Drug and Alcohol Programs (DDAP) announced a joint initiative with Carlow and Waynesburg Universities to address the shortage of qualified addiction professionals within Pennsylvania’s behavioral health workforce.

Funded by DDAP, this pilot program will focus on the recruitment and retention of behavioral health professionals by providing financial assistance for participating students’ educational expenses. At its core, this initiative is designed to strengthen the substance use disorder (SUD) workforce pipeline by financially supporting master’s-level students at Carlow and Waynesburg Universities. Through the DDAP funding, both universities will offer tuition assistance, a stipend during the students’ practicum/internship with a community-based treatment provider, and additional SUD-related training offered by DDAP for students who qualify under each university’s respective programs.

Read the full press release.

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