We’ve spent the last few columns talking about the differences between “medical” care and other types of care for those with substance use disorders. I’ve received a greater number of letters than usual, all of which agreed with the fundamental point that patients appreciate a medical approach to their illness just as they would if they had diabetes. John Doyel wrote, “The more scientific we can be, the better the treatment and respect. I work for a county agency that uses the medical model. We have worked hard to apply ASAM placement criteria, DSM-IV diagnostic criteria, motivational interviewing, etc. It appears to me that the more we apply the medical to substance abuse and chemical dependency disorders, the more our clients are at ease with treatment and the better the outcomes. In my experience, the only group that seems to have a problem with the medical model is the criminal justice ‘business’ which is very invested and dependent on the moral model.”

Several wrote about the shameful fact that physicians are the least likely to approach substance use disorders as if it were a disease — sometimes, going so far as to share with patients their low expectation for recovery. This is an unfortunate underscore of the failure to train physicians regarding this disease. I am always amazed to hear about the low number of trainees going into a field that directly impacts at least 10 percent of the population. The addiction psychiatry fellowships — one year programs with only 100 or so spots available — don’t even fill up each year.

In the meantime, I’ve become increasingly aware of potential regulatory hurdles that may be causing physicians to pause before entering the field. Those of you in New York State are undoubtedly aware of the New York Office of Alcoholism and Substance Abuse Services (OASAS). The role of this state agency is to oversee “the nation’s largest and most diverse addiction system.” OASAS does an excellent job, providing a useful website with all their applicable regulations. Let’s take a close look at Part 810 of the regulations at: http://www.oasas.state.ny.us/regs/810.htm.

The regulations speak of how a “prospective provider of chemical dependence services is required to obtain the prior approval of the Commissioner before” actually opening up such an office. As a licensed physician, I fall under Part 810.7h2ii of the regulations. These note that if I set up a business entity — something I usually would call a medical office — I am exempt from the requirement unless I have someone of another discipline working with me.

So let’s say that I open my office, Yorkville Addictions, Inc., in uptown Manhattan. I bring in a social worker as a partner and the two of us decide that we’d like a nurse to come in a few times a week. I’ve just started a medical practice that focuses on addictive disease very much as Hypertension Consultants, Inc., might be a medical practice focusing on hypertension. And just as the internist owning that company might partner with a nurse or a PA, I’ve brought in a social worker and a nurse.

But OASAS requirements indicate that I can’t do that without going through an incredible number of hoops because I brought in other professionals who aren’t MDs. You can have a group of doctors or a group of social workers, but once you have both in one office, you’re subject to the OASAS regulations. At that point, Yorkville Addictions, Inc., would fall into Part 822 — “Chemical Dependence Outpatient Services.” You can take a look at that from the left side selection bar on the Part 810 page. What you’ll find are an enormous number of requirements in terms of paperwork, applications, and office-based requirements, almost none of which is relevant to the practice of addiction medicine within a physician’s office or within an office fully overseen by a physician.

The regulations are written with the intent of having addiction services rendered without significant clinical medical treatment being provided. In Section 822.7d: A physician, PA, or nurse practitioner must be onsite one hour a week for every 25 active patients. Given the rest of the regulations, during that hour the physician will be signing documents and reviewing treatment, not delivering any care. So on the one hand, a physician can’t open up an office dedicated to treating addiction patients without falling under these regulations, but on the other hand, once he does open such an office, he doesn’t even have to be there more than a couple of hours a week. Who came up with this? And why?

After reading these regulations, I got worried. My own office in Rhode Island is an addiction treatment office where I work with another MD, as well as two LICSW’s. In New York, I’d be in trouble. I went quickly to: http://www.mhrh.state.

ri.us/substance_abuse.htm, where I found that what I do constitutes “outpatient services.” My clinic also falls into the category of “substance abuse facility,” but Rhode Island has smartly included language that indicates private practitioners’ offices are excluded (Section 1.46) from this category. So, my office is legal in Rhode Island but wouldn’t be in New York, at least by my reading of the online documentation.

For the sake of this column, I spoke to several healthcare attorneys about this and got mixed responses. One said that I was exactly correct, and while the other agreed with my interpretation, he pointed out that to his knowledge, no physicians had been stopped from practicing normally as a result of the regulations.

That concerned me. One road near my office is posted at 25 mph. I know the road is never patrolled and that no one has ever been stopped for going 50 mph there. Should that make me feel better about going over the limit?

Dr. Gitlow is on the Board of the American Society of Addiction Medicine and serves as Chair of the American Medical Association’s Task Force on Alcohol. His textbook, Substance Use Disorders: A Practical Guide, will have its second edition released shortly from Lippincott Williams & Wilkins.

This article is published in Counselor,The Magazine for Addiction Professionals, April 2006, v.7, n.2, pp.44-45.

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