From: Mark Parrino [mailto:mark.parrino@aatod.org] 

Sent: Tuesday, May 26, 2009 4:51 PM 

To: EBSA, E-OHPSCA - EBSA 

Subject: Request for Information re: Paul Wellstone and Pete Domenici Mental Health Parity and 

Addiction Equity Act of 2008 

Importance: High

Please find attached AATOD’s letter regarding the above referenced subject. Please confirm 

receipt. Thank you.

Mark 

zzzz z zz 

Mark W. Parrino, M.P.A. 

President 

American Association for the Treatment of Opioid Dependence (AATOD) 

225 Varick Street, 4th Floor 

New York, NY 10014 

Ph: 212.566.5555, x200 

Fax: 212.366-4647 

E-mail: Mark.Parrino@aatod.org

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American Association lor the Treatment of 0pioid Dependence, Inc,

Board of Directors

Mark W Parrino, NI.PA.

Prfsi(/r'r I

IraJ. Marion. M.A.

fjir.st Vicc Plisi(i.itt

New York

George E. Stavros, M.D.

-Se i orrcl Vicr Prl siJ( [l

Arizona

Michael Rizzi

.il rcrsu ri r

Rhode Island

Jina K. Thalmann, L.(-.S.W

-Sa( l( t(tt \ r

Floricla

Board Members

Alabama

Steve Flor a

California

Jason Kle tte r. Ith.D.

Colorado

Eric Ennis, l-.C.S.W.

ConnccticLrt

Richard Bilangi, lVl.S.

Connecticut

Paul Nlclaughlin, N,l.A.

Gcorgia

Stacey Pcarcc

Illinois

Katc Nlahoncl'. I-CSW

lndiana

Grcgory H:rrdin, BS., CAI)A(-ll

Lor.risian:r

lloyc T. Brown, IVl.S.

l\'l:rine

Carric Perkins, Cr\lXIMaryland

Nlassachusct t s

Janice F Kauffman, ll.N., Nl.Plt.

Michigan

Brian McCarroll, Nl.S., D.().

Missouli

Keith E. Spare, M.S.

Ncvada

Shirley Linzy, RN. l\'lS

New Jerscy

Edrvard J. Hipgins. N{.r\.

North Carolina

Kenny House, l.(-A5

0hitr

Pennsylvania

Richard Froncillo, l-C DS

South Carolina

Edward G.Johnson, N{AC. LI'C

Utah

Joel L. N{illard, D.S.\41

Virginia

Edward \i Ohlinger

Washington, DC

Brian Crissman

Washington

Ron Jackson, MSW

N{exictr

Galen E. Rogers, Ph.D.

May 26,2009

Office of Health Plan Standards and Compliance Assistance

Employee Benefits Security Administration

Room N-5653

U.S. Department of Labor

200 Constitution Avenue. NW.

Washington,DC 20210

Alten t ion : MHPAEA Comments

Re: 45 CFR Parts 144 and 146

lcMS-4140-NCl

RIN 0938_AP65

Paul Wellstone and Pete Domenici

Mental Health Parity and

Addiction Equity Act of 2008

To Whom It May Concern:

I arn writing in ref-ererrce tothe Paul Wellstone and Pete Dornenici Mental Health

Parity and Addiction Equity Act of 2008 (MHPAEA).

The American Association for the Treatment of Opioid Dependence (AATOD)

represents more than 850 opioid treatment programs (OTPs), which are

certified/registered by the Substance Abuse and Mental Health services

Administration /Center for Substance Abuse Treatment (SAMfISA/CSAT). The

llation's OTPs treat more tlran 260,000 patients for chronic opioid

dependence/addiction on arly given day.

At the outset, AATOD supported the passage of MHPAEA, especially with the

addition of substance use disorder benefits. We believe that this legislation will

improve access to substance abuse treatmenthroughouthe Urrited States and also

irnprove retention in treatrnent once the patient has made the critical decision to seek

treatrnent for their substance Ltse disorder.

Our Association's remarks are lirnited to how the MHPAEA will incorporate tlre use

of medication-assisted treatment (rnethadone/buprenorphine) for the treatment of

chronic opioid dependence/addiction. lt is understood that the MIIPAEA requires

plans or coverage to ensure that "...the treatrnent limitations, irrcluding lirnits orr the

frequency of treatment, number of visits, days of coverage, or other similar lirnits on

the scope or duration of treatment, applicable to such mental healtlr or substance Llse

disorder benefits are no more restrictive than the predorninant treatment limitations

applied to substantially all rnedical and surgical beneflts covered by the plan."

It is critically irnportant that the implernentation of the provisions of MHPAEA

incorporate what long tenn research and evidence based clinical practice lrave found

with regard to the use of medication-assisted treatment for chronic opioid

dependence/addiction. Tlre hallmark parity coverage should allow the patient to

continue to receive medication-assisted treatment as long as the patient continues to

benefit from such ongoing medical care. The SAMHSA/csAT Treatment

Improvement Protocol (TIP No.43), " Medication-Assisted Treatment for Opioid

L4TOD/EUROPAD t Fotutding Organizing Partners oJ the Workl Fcclt'rotion.lin' tllt Trcatmrtlt ol Opioitl L)t pt rrdorcr
Addiction in Opioid Treatment Programs, references several key research findings in this

regard in Chapter 8, "Approaches to Providing Comprehensive Care and Maximizing Patient

Retention."

"Studies of patients who left medication-assisted treatment (MAT) prematurely

lrave determined that length of retention was tlre most important indicator of

treatment outcomes. Patients who stayed in treatment a year or longer abused

substances less and were rnore likely to engage in constructive activities and

avoid criminal involvement than those who left treatment earlier."

This chapter also referenced research conducted by Drs. Magura and Rosenblum.

"Setting maximum lengths of stay for all patients or emphasizing low-dose

medication goals can discoLrrage rtention and produce poor oLltcomes."

The point is rrot to establish artificial limitations or exclusions, wlrich will be countertlrerapeutic for

tlre patient and limit successful patient outcorne. This perspective is also supported in The Inslitute

of Medicine publication, "Crossing the Quality Chasm: A New l-lealth System for the 2 l" Century"

(March 2001): "Patients should receive care based on the best available scientific knowledge. Care

should not vary illogically from clinician to clinician or from place to place." More than four

decades of research have demonstrated thatthe appropriate use of medicatiotts, such as methadone

and buprenorphine, to treat chronic opioid dependence/addiction in conjunction with

comprehensive need- based treatrnent services, have proven to be extremely cost effective. Almost

all of this treatment is conducted on an outpatient basis as well.

It is also importanto point out that there are special federal and state rules goveming admission to

OTPs in addition to the frequency of patient visits to the treatment prograrn. The federal rules for

OTPs with regard to frequency of patient visits are stipulated in 2l CF'R Paft29l and 42 CFR Part

8, Opioid Drugs in Maintenance arrd Detoxification'I'reatment ofOpioid Addiction. These federal

regulations are promulgated by DHHS/SAMIJSA/CSAT. Illustratively, tlrese federal requirements

stipulate "...that a patient is responsible in handling opioid drugs [and that] the following

restrictions apply: during the first 90 days of treatment. the take-horne supply is limited to a single

dose each week and the patient shall ingest all other doses under appropriate supervision as

provided for under the regulations in this subpaft." lt is importanthat the remaining part of these

regulations be understood, as parity legislation will apply to the use of medication-assisted

treatment for clrronic opioid dependence/addiction.

In summary, we believe that as the above-referenced legislation is being implemented, there should

not be any standardized and/or illogical restrictions on the length of time that a patient may need

access to treatment or medication, as long as the patient continues to benefit from such care. We

appreciate your willingness to take our cornments into account as you begin to implernent this act.

Sincerely yours, /')

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lrf / l/,*

Mark W. Parrino, MPA

President