Ala. Admin. Code r. 580-9-44-.29

Level I-O: Opioid Maintenance Therapy

This regulation establishes operating standards for Level I-O Opioid Maintenance Therapy Programs in Alabama, governing admission criteria, core services, medical and counseling requirements, drug testing protocols, and procedures for addressing positive toxicology results. Operators must maintain written program descriptions, conduct comprehensive medical evaluations prior to admission, provide dosing and counseling seven days per week, and follow specific protocols when clients test positive for illicit substances. Special provisions apply for adolescent admissions, which require prior unsuccessful treatment attempts and written authorization from the State Opioid Treatment Authority.

Ala. Admin. Code r. 580-9-44-.29 - Level I-O: Opioid Maintenance Therapy 

 State Regulations 

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(1)
 Rule Compliance. Each Level I-O Opioid
 Maintenance Therapy Program shall comply with all applicable rules and the
 rules specified in this chapter: 
(a)
 Program
 Description. The entity shall develop, maintain and implement a written program
 description that defines its Level I-O Opioid Maintenance Therapy Program. 
 
1.
 Location. The entity shall specifically
 identify and describe the setting in which the Level I-O Program is provided.
 Services may be provided in any facility that meets all applicable federal,
 state and local certification, licensure, building, life-safety, fire, health
 and zoning regulations, including the DMH facility certification
 standards.

2.
 Admission Criteria.
 The entity shall develop, maintain and document implementation of written
 criteria for admission to its Level I-O Program, in compliance with the
 requirements of Rule
 
580-9-44-.13
(9)
 
 and the following specifications:
(i)
 The
 entity's admission criteria shall specify the target population for its Level
 I-O Program, which shall include, at a minimum: 
 
(I)
 Individuals who are currently
 physiologically dependent upon an opiate drug and who became physiologically
 dependent at least one (1) year prior to seeking admission to Opioid
 Maintenance Therapy.

(II)
 Other
 individuals, as authorized by the entity's medical director, who have a history
 of Opioid use and are susceptible to relapse to Opioid addiction leading to
 high risk behaviors with potentially life-threatening consequences, but who do
 not present with a one (1) year history of addiction, including: 
 
I.
 Pregnant women.

II.
 Individuals who have been released from a
 penal institution within six (6) months of the current admission request, if
 the client was eligible for admission prior to incarceration.

III.
 Individuals who have had a previous
 admission to Opioid maintenance therapy of at least six (6) months duration
 that occurred within two (2) years of the current admission request.

IV.
 Individuals who are HIV
 positive.

(ii)

 The entity shall provide written documentation in each individual clinical
 record that each client admitted to a Level I-O Program for Opioid Maintenance
 or Withdrawal Therapy meets the criteria for Opioid Dependence Disorder, as
 according to the specific diagnostic criteria given in the most recent edition
 of the Diagnostic and Statistical Manual of Mental Disorders of the American
 Psychiatric Association.

(iii)
 The
 entity shall provide written documentation in each individual case record that
 each client admitted to a Level I-O Program meets the dimensional criteria for
 admission to this level of care as defined in the most recent edition of the
 ASAM PPC-2R.

(iv)
 Medical necessity
 of each admission to a Level I-O Program shall be established by the program's
 medical director or a physician authorized by the program's medical director
 and documented in the clinical record.

(v)
 Adolescent Specific Criteria. An entity
 shall not admit an individual under age eighteen (18) to a Level I-O Program
 for Opioid Maintenance Therapy unless the entity can document that: 
 
(I)
 The client has had two (2) unsuccessful
 attempts at drug-free treatment within a twelve (12) month period of time;
 or

(II)
 The client has had two (2)
 unsuccessful attempts at short-term detoxification.

(III)
 The entity has obtained written
 authorization of the admission from the State Opioid Treatment Authority
 (SOTA).
I.
 The entity shall develop, maintain
 and document implementation of written policies and procedures which govern the
 process utilized to request and obtain written authorization from the SOTA
 prior to admission of an individual under age eighteen 18 to a Level I-O
 Program.

3.
 Core Services. Each Level I-O Program
 shall demonstrate the capacity to provide a basic regimen of treatment services
 appropriate to the client's developmental and cognitive levels and other
 assessed needs.
(i)
 At a minimum, the entity
 shall demonstrate and document its capacity to provide the following core
 services:
(I)
 Placement assessment.

(II)
 Medication management.

(III)
 Medication administration.

(IV)
 Alcohol and/or drug
 screening/testing.

(V)
 Individual
 counseling.

(VI)
 Group
 counseling.

(VII)
 Family
 counseling.

(VIII)

 Psychoeducation.

(IX)
 Case
 management:
I.
 Case planning.

II.
 Linkage.

III.
 Advocacy.

IV.
 Monitoring.

(ii)
 Medical Services. The entity shall have
 medical protocols established for I-O Level of Care by a licensed physician or
 staff or under contract with the entity as the medical director. The medical
 protocol shall be in compliance with the program standards, ethics and
 licensure requirements of the medical profession.

(iii)
 Mental Health Services. The entity
 shall develop, maintain and document implementation of policies and procedures
 to ensure that clients with mental health needs are identified through
 assessment services and have access to appropriate care concurrently with
 Opioid Maintenance or Withdrawal Therapy.

(iv)
 Family Support. The entity shall
 initiate and document in the client record: 
 
(I)
 Continuous efforts to involve the
 client's family and other natural supports in the treatment process.

(II)
 Family and other natural supports'
 participation in the client's treatment process.

4.
 Therapeutic Component Implementation. 
 
(i)
 Each Level I-O Program shall provide
 written documentation of compliance with all applicable local, state and
 federal regulations, including Federal Regulation 42 CFR Part 
8
, DEA,
 Certificate of Need, etc. in addition to all applicable sections of the rules
 set forth, herein.

(ii)
 Each Level
 I-O Program shall establish a written schedule of operating hours and services
 that shall:
(I)
 Provide for dosing and
 counseling services seven (7) days each week.

(II)
 Establish hours of operation that are
 flexible to accommodate the majority of client school, work and family
 responsibility schedules.

(III)

 Provide access to clinical services personnel twenty-four (24) hours a day,
 seven (7) days a week.
I.
 The physical plant
 is of adequate size to accommodate the proposed number of clients, required
 program activities, and provide a safe, therapeutic environment that supports
 enhancement of each client's well-being and affords protection of privacy and
 confidentiality.

(iii)
 Counseling Services: The entity shall
 document the provision of scheduled counseling and recovery support services
 and activities that shall, at a minimum, include: 
 
(I)
 Interventions that address: 
 
I.
 Emotional and psychological
 needs.

II.
 Health
 education.

III.
 Medication
 administration and monitoring.

5.
 Assessment: The entity shall comply with
 all standards set forth in Rule
 
580-9-44-.13
(7)
 
 of these rules and in addition, shall comply with the requirements of this
 section:
(i)
 Before an entity admits an
 individual to a Level I-O Program, the program's medical director, or a
 physician or physician extender properly authorized by the medical director,
 shall conduct and document the findings of a medical evaluation.

(ii)
 A pregnancy test shall be completed, and
 the results documented, for each female of childbearing potential prior to the
 initiation of Opioid Maintenance Therapy, or any medically assisted withdrawal
 or detoxification procedures.

(iii)

 A comprehensive medical examination that includes the following components, at
 a minimum, shall be completed and documented in the clinical record, within
 fourteen (14) days of each admission:
(I)
 A
 complete medical history.

(II)
 A
 tuberculosis (TB) skin test or chest x-ray if the skin was ever previously
 positive.

(III)
 Screening tests for
 STDs.

(IV)
 Other laboratory tests
 as clinically indicated by the client's history and physical
 examination.

(iv)
 An
 annual medical examination shall be conducted and documented in the clinical
 record by the program's medical director, or a physician or physician extender
 authorized by the program's medical director.

6.
 Client Orientation: 
 
(i)
 All clients shall be oriented to the
 Opioid Therapy process prior to administration of any medication.

(ii)
 The entity shall provide written
 documentation that each client, upon admission and throughout the treatment
 process, receives oral and written information that explains in a manner
 understood by the client:
(I)
 Signs and
 symptoms of overdose and when to seek emergency assistance.

(II)
 A description of the medications to be
 administered by the program, including potential: 
 
I.
 Benefits.

II.
 Risks.

III.
 Side effects.

IV.
 Drug interactions.

(III)
 Common myths about Opiate Maintenance
 Therapy and medications used in the treatment and withdrawal process.

(IV)
 The nature of addictive
 disorders.

(V)
 The goals and
 benefits of medication assisted treatment and the process of
 recovery.

(VI)
 Noncompliance and
 discharge procedures, including administrative withdrawal from
 medication.

(VII)
 Toxicology
 testing procedures.

(VIII)

 Medication dispensing procedures.

7.
 Drug Testing: The entity shall develop,
 describe in writing and document implementation of an organized process to
 monitor drug use by program participants, which shall, at a minimum, comply
 with the standards provided in Rule
 
580-9-44-.13
(25)
,
 and include the following specifications:
(i)

 The results of a drug test shall be utilized as a guide to review and modify
 treatment approaches and not as the sole criterion to discharge a client from
 treatment.

(ii)
 Baseline toxicology
 tests shall be completed on the day of Diagnostic Interview Examination that
 shall, at a minimum, screen for:
(I)

 Opiates.

(II)
 Methadone.

(III)
 Benzodiazepines.

(IV)
 Barbiturates.

(V)
 Cocaine.

(VI)
 Amphetamines.

(VII)
 Tetrahydrocannabinol.

(VIII)
 Alcohol.

(IX)
 Any other drug known to be frequently
 abused in the locality of the Opiate Maintenance Therapy
 Program.

(iii)
 Random
 drug tests shall be conducted at least once per month throughout the duration
 of each client's participation in Opioid Maintenance Therapy. A minimum of
 twelve (12) drug tests shall be conducted per year.

(iv)
 The entity shall document the provision
 of a minimum of two (2) drug tests per month for each client during the first
 ninety (90) days in Opioid Maintenance Therapy and for those, otherwise, in
 Phase 1 of the program.

(v)
 The
 entity shall document the utilization of drug testing cutoff concentrations as
 follows:
(I)
 Marijuana: 100 ng/ml

(II)
 Cocaine: 300 ng/ml

(III)
 Opiate: 300 ng/ml

(IV)
 Amphetamine/methamphetamine: 1000
 ng/ml

(V)
 Benzodiazepine: 200
 ng/ml

(VI)
 Methadone: 300
 ng/ml

(VII)
 Barbiturates: 200
 ng/ml

(VIII)
 Alcohol: .03
 gm/dl

(IX)
 In cases where Opiate
 Maintenance drugs other than methadone are being used, the clinic should
 contact the State Opioid Treatment Authority to determine the acceptable
 immunoassay cut-off concentrations.

(vi)
 The entity shall provide documentation
 that all drug tests are conducted by a laboratory certified by an independent,
 federally approved accreditation entity.

(vii)
 The results of all drug tests shall be
 filed in the clinical record.

8.
 Procedure for Addressing Positive
 Toxicology Reports. The entity shall develop, maintain and document
 implementation of written policies and procedures that establish protocols for
 addressing positive toxicology results for illicit drugs and negative results
 for drugs administered by the Opioid Maintenance Therapy Program that shall, at
 a minimum, include the following specifications: 
 
(i)
 Baseline drug testing results shall be
 discussed with the client and documentation of this discussion recorded as a
 progress note in the clinical record.

(ii)
 At his/her next scheduled clinic visit
 after receiving a positive alcohol/drug screen, clients shall be informed of
 drug testing results that are positive for substances of abuse, or negative for
 Opioid Maintenance Therapy medication. Following client notification, the
 entity shall implement the following procedures, as appropriate: 
 
(I)
 New Clients. During the first ninety (90)
 days of treatment, the first drug testing report that is positive for
 substances of abuse or negative for treatment medication, after baseline
 testing, shall result in a meeting between the client and the client's primary
 counselor to review the treatment plan, and to modify or intensify treatment
 services as appropriate to the client's current needs.

(II)
 Clients with take-home privileges. 
 
I.
 A positive toxicology report for illicit
 drugs or a negative toxicology result for treatment medication shall require
 that the client with take-home privileges, at a minimum: 
 
A.
 Be placed on probation for ninety (90)
 days.

B.
 Receive a minimum of two
 (2) random drug screens per month during the probationary period.

C.
 Collaborate with his/her primary counselor
 for discussion of the toxicology results and for service plan modification as
 according to the client's needs.

II.
 A second toxicology result that is
 positive for substances of abuse or negative for treatment medication during a
 probationary period shall require that the client with take-home privileges, at
 a minimum:
A.
 Transfer to a lower dosing
 phase.

B.
 Receive a minimum of two
 (2) random drug screens per month.

C.
 Participate in a clinical staffing. Mental
 Health Chapter 580-9-44 Revised 3/17/23 9-44-173

D.
 Collaborate with the treatment team to
 develop and implement a plan for remedial action.

(III)
 Subsequent Drug Tests for All Clients.
 For subsequent drug testing results that are positive for substances of abuse
 or negative for treatment medication the entity shall take steps to provide
 assistance for each client, as according to assessed needs, that shall include
 but shall not be limited to:
I.
 Treatment team
 staffings in collaboration with the client.

II.
 Continued assessment services of the
 client's biopsychosocial needs and levels of functioning.

III.
 Re-evaluation of the client's medication
 dosage, plasma levels, metabolic responses and adjustment of the dosage for
 adequacy and client comfort.

IV.

 Assessment for co-occurring disorders, prescribing therapy and
 psycho-pharmacotherapy as needed.

V.
 Intensify counseling or add of other types
 of services.

VI.
 Treatment of
 medical or other associated problems.

VII.
 Consideration of alternative opiate
 addiction treatment medications.

VIII.
 Detoxification from substances of abuse
 while maintaining the client on Opioid pharmacotherapy.

IX.
 Initiating a change of counselors when
 indicated.

X.
 Providing family
 intervention.

(IV)
 If any
 client has six (6) or more consecutive toxicology results that are positive for
 substances of abuse or negative for treatment medication, the entity shall
 inform the client that administrative withdrawal procedures will begin
 immediately and a referral will be made to an appropriate level of care unless
 the entity's medical director: 
I.
 Provides
 objective clinical contraindications of the need for this action.

II.
 Develops a written intervention plan in
 consultation with the client and the client's treatment team that shall at a
 minimum, include provisions for:
A.

 Detoxification from substances other than the maintenance therapy drug; and/
 or

B.
 Intensified counseling and
 other services.

III.

 Documents all actions taken, in this regard, as appropriate.

IV.
 The entity shall maintain a data base of
 drug testing results which shall at a minimum:

V.
 List each client by unique client
 identifier, date of birth, gender, date of each drug test, identify each drug
 for which tests are completed and the results of each test.

VI.
 Allow for development of aggregate
 reports of each variable as well sorting of data by each
 variable.

9.
 Take Home Medication: The entity shall
 develop, maintain and document implementation of written policies and
 procedures that govern the processes utilized to provide clients with
 unsupervised use of program dispensed Opioid treatment medication. At a
 minimum, these policies and procedures shall include the following
 specifications:
(i)
 The entity's medical
 director, in consultation with the client's treatment team, shall make all
 decisions relative to dispensing Opioid treatment medication to clients for
 unsupervised use, in consideration of the following minimum criteria: 
 
(I)
 Absence of recent abuse of drugs
 (narcotic or non-narcotic), including alcohol.

(II)
 Regularity of clinic
 attendance.

(III)
 No observed,
 reported, or otherwise known serious behavioral problems.

(IV)
 Absence of known recent criminal
 activity, e.g., drug dealing.

(V)

 Stability of the client's home environment and social relationships.

(VI)
 Length of time in treatment.

(VII)
 Assurance that take-home medication can
 be safely stored within the client's home.

(VIII)
 Whether the rehabilitative benefit to
 the client derived from decreasing the frequency of clinic attendance outweighs
 the potential risks of diversion.

(ii)
 Decisions to approve unsupervised use of
 Opioid medications, including the rationale for the approval, shall be
 documented in the clinical record.

(iii)
 Patients must have in their possession
 a secure locking storage device in order to receive take-home medication. There
 are no exceptions.

(iv)
 The amount
 of take-home medication shall be based on the clinical judgment of the
 physician in consultation with the multidisciplinary treatment team. If it is
 determined that a client meets the criteria for unsupervised dosing the supply
 shall be limited to the following schedule: 
 
(I)
 Phase 1 Treatment. Clients who are not
 eligible for any take home medication shall be designated by the program as in
 Phase 1 of Opioid Maintenance Therapy.
I.

 During the first ninety (90) days of treatment, clients shall not be eligible
 for any take home medication.

II.

 Twice-a-month drug tests shall document that each client in Phase I is free of
 all substances of abuse including alcohol and positive for the prescribed
 maintenance drug for at least ninety (90) consecutive days in order to be
 eligible for consideration for unsupervised dosing.

(II)
 Phase 2 Treatment. Clients in treatment
 between ninety-one (91) and one hundred eighty (180) days, who satisfy the
 criteria specified in Rule
 
580-9-44-.29
 8(i)(II) shall be
 eligible for a take-home supply that shall not exceed two (2) doses per week. 
 
I.
 Clients who are eligible for a two (2) day
 take home medication supply shall be designated by the program as in "Phase
 
2"
 of Opioid Maintenance Therapy.

II.
 A minimum of one (1) random drug test per
 month must be conducted while the patient is in Phase 2.

III.
 It shall be documented that the client
 is free of all substances of abuse including alcohol and positive for the
 prescribed maintenance drug for at least ninety (90) consecutive days in order
 to be considered for Phase 2 unsupervised dosing.

(III)
 Phase 3 Treatment. Clients in treatment
 between one hundred eighty-one (181) and two-hundred seventy (270) days, who
 satisfy the criteria specified in Rule
 
580-9-44-.29
 8(i)(II) shall be
 eligible for a take-home supply that shall not exceed three (3) doses per week.
 
I.
 Clients who are eligible for a three (3)
 day take home medication supply shall be designated by the program as in Phase
 3 of Opioid Maintenance Therapy.

II.
 A minimum of one (1) random drug test per
 month must be conducted while the patient is in Phase 3.

III.
 It shall be documented that the client
 is free of all substances of abuse including alcohol and positive for the
 prescribed maintenance drug for at least one hundred eighty (180) consecutive
 days in order to be considered for Phase 3 unsupervised
 dosing.

(IV)
 Phase 4
 Treatment. Clients in treatment between two hundred seventy-one (271) and three
 hundred sixty-five (365) days, who satisfy the criteria specified in Rule
 
580-9-44-.29
 8(i)(II) shall be
 eligible for a take-home supply that shall not exceed six (6) doses per week 
 
I.
 Clients who are eligible for a six (6) day
 take home medication supply shall be designated by the program as in Phase 4 of
 Opioid Maintenance Therapy.

II.
 A
 minimum of one (1) random drug test per month must be conducted while the
 patient is in Phase 4.

III.
 It
 shall be documented that the client is free of all substances of abuse
 including alcohol and positive for the prescribed maintenance drug two hundred
 seventy (270) consecutive days in order to be considered for Phase 4
 unsupervised dosing.

(V)

 Phase 5 Treatment. After two (2) years of continuous treatment with
 uninterrupted clean drug screens, client shall be eligible for up to a thirteen
 (13) day take home medication supply.
I.

 Clients who are eligible for a thirteen (13) day take home medication supply
 shall be designated by the program as in Phase 5 of Opioid Maintenance
 Therapy.

II.
 A minimum of one (1)
 random drug test per month must be conducted while the patient is in Phase
 5.

(iv)

 Temporary Special Take-Home Medication for Non-Emergency: The entity shall
 develop, maintain and document implementation of written policies and
 procedures that govern the process utilized to provide temporary take home
 medication for exceptional circumstances, which shall at a minimum include the
 following specifications:
(I)
 The need for
 temporary special unsupervised take-home medication shall be clearly delineated
 with verifiable documentation in the clinical record.

(II)
 A client seeking approval for temporary
 special unsupervised take-home medication shall, at a minimum, meet the
 criteria to determine eligibility for take home medication specified in Rule
 
580-9-44-.29
 9.

(III)
 Requests for temporary special
 take-home medication shall be approved in writing by the entity's medical
 director, the State Opioid Treatment Authority and SAMHSA.

(IV)
 The provision and supply of temporary
 special unsupervised take-home medication shall be at the direction of the
 State Opioid Treatment Authority.

(v)
 Temporary Special Take-Home Medication
 for Emergency: The entity shall develop, maintain and document implementation
 of written policies and procedures that govern the process utilized to provide
 emergency take-home medication for exceptional circumstances, which at a
 minimum include:
(I)
 The need for emergency
 unsupervised take-home medication shall be clearly delineated with verifiable
 documentation in the client's clinical record.

(II)
 Requests for emergency take-home
 medication shall be approved in writing by the entity's Medical Director and
 shall not exceed a three (3) day medication supply at any one time. 
 
I.
 Situations that might warrant emergency
 take-home medication include:
A.
 Death in the
 family.

B.
 Illness.

C.
 Inclement weather.

D.
 Other uniquely identified
 situations.

(vi)
 Hardship Waiver. The entity shall
 develop, implement and document implementation of written policies and
 procedures to address requests for hardship exceptions to the rules for early
 phase advancement:
(I)
 Specify the conditions
 under which a client may request a hardship waiver and the conditions required
 for its consideration.

(II)

 Describe the process utilized to ensure continuity of care when a client is
 unable, due to a verifiable hardship, to report to the program for routine
 ingestion of medication.

(III)

 Describe the program's use of Chain-of Custody Record procedures and identify
 the specific persons/positions responsible in each step of the process, along
 with the specifications of their duties.

(IV)
 Include provisions for hardship
 exception requests to be authorized by the entity's medical director and
 submitted to the State Opioid Treatment Authority and to SAMHSA for review and
 approval.

(V)
 Provide for all
 considerations given, recommendations for and conditions of hardship waivers,
 as well as, denials of such to be documented in the clinical
 record.

(vii)
 Denial or
 Rescinding of Take-Home Privileges. The entity shall develop, maintain and
 document implementation of policies and procedures which govern the process
 utilized to deny or rescind approval of take-home
 privileges.

10.
 Diversion
 Control: The entity shall develop, maintain and document implementation of a
 written plan to reduce the possibility of diversion of controlled substances
 from legitimate treatment to illicit use. The diversion control plan shall, at
 a minimum, include the following elements:
(i)

 A process for routine surveillance and monitoring of the internal and external
 treatment environment to identify diversion problems.

(ii)
 A process for continuous examination of
 dosing and take-home dispensing practices to identify weaknesses in the
 dispensing of medication that could lead to diversion problems.

(iii)
 Procedures for clients who are
 dispensed three (3) or more take-home doses to receive a minimum of two (2)
 call-backs annually.

(iv)
 A process
 to address identified diversion problems through corrective and preventive
 efforts.

(v)
 Specific assignment to
 the entity's medical and administrative staff for implementation of the
 diversion control measures and functions identified in the diversion control
 plan.

11.
 Dosing: The
 entity shall develop, maintain and document implementation of written policies
 and procedures to govern the process of drug dispensing and administration that
 shall, at a minimum, include the following specifications: 
 
(i)
 A standardized process that includes the
 use of identification by photograph shall be utilized to properly establish the
 identity of each individual before any Opioid Therapy Medication is
 administered.

(ii)
 The entity shall
 maintain current procedures adequate to ensure that each Opioid dependency
 treatment medication used by the program is administered and dispensed in
 accordance with approved product labeling.

(iii)
 Dosing and administration decisions,
 including prescribing, reassessment and regulation shall only be made by an
 authorized program physician who is familiar with the most up-to-date product
 labeling.

(iv)
 Any deviations from
 the approved labeling, including deviations with regard to dose, frequency, or
 the conditions of use described in the approved labeling shall be specifically
 documented in the case record.

(v)

 An authorized program physician shall employ clinical judgment to determine the
 individual dose of Opioid therapy medication, with consideration of the
 following stipulations, at a minimum:
(I)
 The
 initial dose of methadone administered on the first visit shall not exceed 25
 mg.

(II)
 Subsequent doses of
 medication shall be:
I.
 Individually
 determined based upon the physician's evaluation of the history and present
 condition of the client.

II.

 Reviewed and updated as according to the client's treatment plan and in
 consideration of the following criteria:
A.

 Cessation of withdrawal symptoms.

B.
 Cessation of illicit Opioid use as
 measured by:
(A)
 Negative drug
 tests.

(B)
 Reduction of
 drug-seeking behavior.

C.

 Establishment of a blockade dose of an agonist.

D.
 Absence of problematic craving as measured
 by:
(A)
 Subjective report.

(B)
 Clinical
 observations.

E.
 Absence
 of signs and symptoms of too large an agonist dose after an interval adequate
 for the client to develop complete tolerance to the blocking
 dose.

(vi)
 A process shall be established wherein
 the dosage to be dispensed shall be verified with the current dosage ordered
 and ingestion observed and documented by the person who administers the Opioid
 dependency treatment medication.

(vii)
 Methadone shall be dispensed in oral
 form in one liquid dose per container.

(viii)
 Buprenorphine shall be dispensed in
 sublingual tablets.

(ix)
 A process
 shall be established to address the entity's response, in regard to dosing, to
 individuals who are objectively intoxicated or who are experiencing other
 problems that would render the administration of methadone
 unsafe.

12.
 Split Dosing:
 The organization shall have a written split dosage policy that shall: 
 
(i)
 Include input from the program physician
 in consultation with the multidisciplinary treatment team and the
 SOTA.

(ii)
 Accurately reflect that
 split dosing is guided by outcome criteria that shall include: 
 
(I)
 The client complains that the dosage
 level is not holding.

(II)
 The
 client exhibits signs and symptoms of withdrawal.

(III)
 The physician employs peak and trough
 criteria for split dosing, if appropriate.

(IV)
 The physician is unable to obtain a peak
 and trough ration for 2.0 or lower, increasing intervals of dosing may be
 appropriate.

(V)
 Addressing the
 failure of all avenues of stabilization.

(VI)
 Addressing stabilization failures with
 the client involving the physician and multidisciplinary
 team.

(iii)
 Include
 provisions for education of the client on the rationale for split dosing and
 take-home medication.

13.

 Guest Dosing: The entity shall develop, maintain and document implementation of
 dosing policies and procedures for the provision of medication to a guest
 client in a program in which the client is not enrolled that shall, at a
 minimum specify:
(i)
 The sending program's
 responsibilities to, at a minimum:
(I)
 Develop
 a document to utilize in transmitting all relevant client and dosing
 information to the receiving agency to request guest dosing
 privileges.

(II)
 Forward this
 document to the receiving program.

(III)
 Provide the client with a copy of the
 document that was sent to the receiving agency.

(IV)
 Verify receipt of the information sent
 to the receiving program.

(V)

 Verify that the client understands all stipulations of the guest dosing process
 including, but not limited to, fees, receiving program contacts, dosing times
 and procedures.

(VI)
 Accept the
 client upon return from guest dosing unless other arrangements have been
 made.

(VII)
 Document all procedures
 implemented in the guest dosing process in each client's case
 record.

(ii)
 The
 receiving program's responsibilities to, at a minimum: 
 
(I)
 Verify receipt of the sending program's
 request for guest dosing privileges and acceptance or rejection of the client
 for guest medication within forty-eight (48) hours of the request.

(II)
 Communicate any requirements of the
 receiving program that have not been specified on the document submitted by the
 sending program.

(III)
 Establish a
 process for medical personnel to verify dose prior to dosing.

(IV)
 Document all procedures implemented in
 the guest dosing process in each client's case record.

(iii)
 If guest dosing exceeds fourteen (14)
 days, a drug screen shall be obtained.

(iv)
 Guest dosing shall not exceed
 twenty-eight (28) days.

14.
 Multiple Client Enrollments: The entity
 shall develop, maintain and document implementation of written policies and
 procedures established to ensure that it does not admit or provide medication
 for an individual who is enrolled in another Opioid Treatment Program. The
 policies and procedures shall include the following components, at a minimum: 
 
(i)
 The State Opioid Treatment Authority
 shall establish written guidelines, incorporated herein by reference, for
 participation in a central registry process to aid in the prevention of
 multiple enrollment of a client in more than one Opioid Maintenance Therapy
 Program at the same time. Each OMT Program shall provide written documentation
 of adherence to the State Opioid Treatment Authority guidelines that shall, at
 a minimum, include the following specifications: 
 
(I)
 The entity shall make a disclosure to the
 central registry at each of the following occurrences: 
 
I.
 A client is admitted for Opioid
 Maintenance Therapy.

II.
 A client
 is transferred to another provider for Opioid Maintenance Therapy.

III.
 A client is discharged from Opioid
 Maintenance Therapy.

(II)

 The entity shall make disclosures in the format and within timeframes
 established by the State Methadone Authority.

(III)
 The entity shall limit disclosures to
 client identifying information and the dates of admission, transfer and
 discharge.

(IV)
 The entity shall
 obtain the client's written consent, in accordance with 42 CFR Part 
2
, prior to
 making any disclosures to the central registry.

(V)
 The entity shall inform each client of
 the required written consent for participation in the central registry before
 services are initiated.

(VI)
 The
 entity shall deny admission to individuals who refuse to provide written
 consent for disclosures to the central registry and shall document these
 denials in the case record.

(ii)
 The entity shall obtain the client's
 written consent, in accordance with 42 CFR Part 
2
, to photograph the applicant
 at the time of admission. The photograph shall be maintained in the client's
 case record.

(iii)
 The entity shall
 require that all clients show proof of identification in the form of an
 official state driver's license or a non-driver's license issued by the state's
 Department of Public Safety. A copy of current identification will be
 maintained in the clinical record.

15.
 Medically Supervised Withdrawal: The
 entity shall develop, maintain and document implementation of written policies
 and procedures that govern the processes utilized to withdraw clients from
 Opioid maintenance medication. At a minimum, the policies and procedures shall
 include the following specifications:
(i)
 A
 process for voluntary medically supervised withdrawal shall be established that
 shall:
(I)
 Acknowledge that participation in
 Opioid Maintenance Therapy is voluntary and that a client is free to leave
 treatment at any time.

(II)

 Identify the steps to be taken by the entity when a client and program
 personnel agree on a need to initiate withdrawal procedures.

(III)
 Identify the steps to be taken by the
 entity when the client requests withdrawal against the medical advice of the
 program's personnel.

(IV)
 Ensure
 the availability of a variety of supportive options to improve the chances of a
 successful episode of medically supervised withdrawal.

(V)
 Establish the protocol wherein the Opioid
 Maintenance Therapy Program resumes medication assisted treatment if the client
 experiences impending or actual relapse.

(ii)
 A process for involuntary medically
 supervised withdrawal shall be established that shall: 
 
(I)
 Identify the circumstance under which
 involuntary administrative withdrawal procedures will be implemented.

(II)
 Identify the steps to be taken and
 delineate the responsibilities of program personnel in implementation of
 involuntary administrative withdrawal procedures.

(III)
 Ensure the availability of a variety of
 supportive options to improve the chances of a successful episode of medically
 supervised withdrawal.

(IV)
 Provide
 for referral or transfer of the client to an appropriate treatment program upon
 completion of the withdrawal process.

(iii)
 The entity's medical director shall
 approve all requests for voluntary and involuntary withdrawal from Opioid
 Therapy medication.

(iv)
 Clients
 who have been determined by the program's medical director or other authorized
 program physician to be currently physiologically dependent on Opioids may
 participate in medically supervised withdrawal, regardless of age.

(v)
 The entity's medical director shall
 establish each individual's withdrawal schedule in accordance with sound
 medical treatment and ethical considerations.

(vi)
 No set dosage reduction schedules shall
 be established for any patient whether voluntarily or involuntarily
 participating in medically supervised withdrawal. Dosage reduction schedules
 shall be based upon objective assessment of each client's unique
 needs.

(vii)
 A medically supervised
 withdrawal schedule for administrative withdrawal shall be for a time period of
 not less than thirty (30) days, unless otherwise clinically contraindicated. In
 cases of clinical contraindication, supporting documentation shall be entered
 in the client's case record by the medical director or a program physician
 operating under the supervision and authority of the medical
 director.

(viii)
 Take-home
 medications shall not be allowed during medically supervised
 withdrawal.

(ix)
 A history of one
 (1) year physiologic dependence shall not be required for admission to an
 Opioid Maintenance Therapy Program for supervised withdrawal.

(x)
 Clients who have two (2) or more
 unsuccessful detoxification episodes within a twelve (12) month period shall be
 assessed by the entity's medical director for other forms of
 treatment.

(xi)
 An entity shall not
 admit a client for more than two (2) detoxification episodes in one (1)
 year.

(xii)
 Drug screens during
 detoxification shall be performed as follows: 
 
(I)
 An initial drug screen shall be performed
 at the beginning of the detoxification process.

(II)
 At least one (1) random screen shall be
 performed monthly during the detoxification
 process.

16.

 Women and Pregnancy Services: The entity shall develop, maintain and document
 implementation of written policies and procedures to address the needs of women
 which shall, at a minimum, include the following requirements: 
 
(i)
 The entity shall acknowledge by policy
 and practice that pregnant women are the number one treatment priority and
 cannot be denied treatment access solely because of pregnancy. 
 
(I)
 When an organization is unable to provide
 services for a pregnant woman, the State Opioid Treatment Authority shall be
 contacted immediately for assistance with placement.

(ii)
 The entity shall have a written
 description of the procedures utilized to:
(I)

 Inform each female client of the possible risks and benefits of the use of
 Opioid Maintenance Therapy during pregnancy.

(II)
 Document in the case record that this
 information has been provided to the client.

(iii)
 The entity shall describe in writing
 and document implementation of the process used to provide pregnant clients
 with access or referral to:
(I)
 Prenatal
 care.

(II)
 Pregnancy/parenting
 education.

(III)
 Postpartum
 follow-up.

(iv)
 The
 nature of services provided in relation to a client's pregnancy shall be
 documented in the case record and signed or countersigned by the entity's
 medical director.

(v)
 When the
 woman consents to a referral for pregnancy related care, or if the woman is
 already under the care of a physician for her pregnancy, the entity shall
 obtain the woman's informed consent to ensure reciprocity in the exchange of
 pertinent clinical information between the woman's perinatal specialist or
 obstetrician and the OMT Program.

(vi)
 When the woman refuses an appropriate
 referral for prenatal services, the entity shall: 
 
(I)
 Utilize informed consent procedures to
 have the client formally acknowledge, in writing, that the Opioid Maintenance
 Therapy Program offered a referral to prenatal services, but the client refused
 the offer.

(II)
 Provide the client
 with basic prenatal instruction on maternal, physical, and dietary care as part
 of the Opioid Maintenance Therapy Program counseling services and document
 service delivery in the clinical record.

(vii)
 The entity shall provide written
 documentation of implementation of the following procedures in regard to care
 for pregnant women:
(I)
 Clients who become
 pregnant during treatment shall be maintained on the pre-pregnancy dosage, if
 effective as determined by the entity's medical director and the client and
 shall apply the same dosing principles as used with any other non-pregnant
 person served.

(II)
 The initial
 methadone dose and the subsequent induction and maintenance dosing strategy for
 a person who is newly admitted and pregnant shall reflect the same effective
 dosing protocols used for all other persons served.

(III)
 The methadone dose shall be monitored
 carefully, especially during the third trimester and adjustments made as
 needed.

(viii)
 The entity
 shall describe in writing and document in the clinical record the process
 utilized if a pregnant woman elects to withdraw from methadone which shall, at
 a minimum, include the following requirements: 
 
(I)
 A physician experienced in addiction
 medicine shall supervise the withdrawal process.

(II)
 Regular fetal assessments, as
 appropriate for gestational age, shall be part of the withdrawal
 process.

(III)
 Education shall be
 provided on medically supervised withdrawal and the impact of medically
 supervised withdrawal services on the health and welfare of unborn
 children.

(IV)
 Withdrawal
 procedures shall adhere to accepted medical standards of care for women who are
 pregnant.

(V)
 Withdrawal procedures
 shall adhere to accepted medical standards regarding adequate dosing
 strategies.

(VI)
 When providing
 medically supervised withdrawal services to pregnant women whose withdrawal
 symptoms cannot be eliminated, referrals to inpatient medical programs shall be
 made.

(ix)
 The entity
 shall describe in writing and document implementation of policies and
 procedures, including informed consent, to ensure appropriate post-pregnancy
 follow-up and primary care for the new mother and well-baby care for the
 infant.

17.
 Medication
 Management: The entity shall comply with all standards set forth in Rule
 
580-9-44-.13
 (23-24) of these
 rules, and, in addition, shall comply with the requirements of this section: 
 
(i)
 The entity's clinical records and client
 outcomes shall indicate that medications used in the Opioid Maintenance Therapy
 Program are sufficient to:
(I)
 Produce the
 desired response.

(II)
 Provide
 freedom from adverse abstinence symptoms for the desired length of
 time.

(III)
 Block the effects of
 other Opiates without producing euphoria or other undesirable
 effects.

(ii)
 The program
 shall provide written documentation, which indicates all medications used in
 the Opioid Maintenance Therapy Program are: 
 
(I)
 Approved by the Food and Drug
 Administration for the treatment of Opioid addiction.

(II)
 Dispensed according to product
 labeling.

(III)
 Managed using
 written procedures that ensure secure storage, accurate dosage and safe
 handling,

(IV)
 Controlled using a
 method to ensure that an accurate inventory of all medication in stock is
 available.

(iii)
 The
 entity shall develop, maintain and document implementation of written policies
 and procedures for dispensing medication used in Opioid Maintenance and
 Withdrawal Therapy, which shall, at a minimum: 
 
(I)
 Ensure that the program's medical
 director or other program physician authorized by the medical director: 
 
I.
 Initiates all medication orders and/or any
 dosage change.

II.
 Documents all
 medication orders and/or any dosage change in the clinical
 record.

(II)
 Ensures that
 each dose is recorded in the clinical record of the person served.

(III)
 Ensures that take-home medications are
 properly labeled, which shall include, at a minimum: 
 
I.
 Name of Opioid Maintenance Therapy
 prescribing clinic.

II.
 Address of
 Opioid Maintenance Therapy prescribing clinic.

III.
 Telephone number of Opioid Maintenance
 Therapy prescribing clinic.

IV.

 Client's name.

V.
 Medication
 name.

VI.
 Dose.

VII.
 Physician's name.

VIII.
 Date filled.

IX.
 Directions for single use.

X.
 Warning: Caution; Federal law prohibits
 the transfer of this drug to any person other than the patient for whom it was
 prescribed.

(iv)
 Ensure that that take-home medication is
 packaged in child-proof containers designed to reduce the risk of accidental
 ingestion.

18.
 Client
 Transfers: The Level I-O Program shall develop, maintain and document
 implementation of written policies and procedures to effect orderly transfer of
 clients between substance abuse programs, which shall, at a minimum, address
 the following specifications:
(i)
 The entity
 shall meet the standards set forth in these rules for client
 transfers.

(ii)
 A client's request
 for transfer to another Level I-O Program shall be honored without restriction,
 even if the client has an outstanding financial balance.

(iii)
 Records to the receiving substance
 abuse program shall be provided promptly and shall include, at a minimum: 
 
(I)
 Original date of admission for the
 current treatment episode.

(II)

 Current treatment phase and date entering phase.

(III)
 Urinalysis results for the past twelve
 (12) months.

(IV)
 Dose level, to be
 confirmed by nursing staff at transferring clinic and documented in the
 clinical record.

(V)
 Most recent TB
 test results and date of test.

(VI)

 Reason for transfer.

(VII)
 Other
 information as requested by the receiving program and specified in an
 appropriate client authorization for release of
 information.

(iv)
 All
 client records shall be complete and up to date at the time of
 transfer.

(v)
 Reports to the DMH
 Central Registry shall be completed at the time of
 transfer.

19.

 Documentation: The entity shall comply with all standards set forth in Rule
 
580-9-44-.13
(21)
 
 of these rules, and, in addition, shall comply with the requirements of this
 section:
(i)
 Clinical records of clients
 receiving Opioid Maintenance or Withdrawal Therapy shall include the following
 documentation:
(I)
 That clients have been
 questioned about being pregnant and informed about pregnancy and physiological
 implications with Opiate maintenance drugs.

(II)
 Support services were recommended and
 utilized when needed.

(III)
 An
 individualized clinical note for each occurring clinical or medical
 encounter.

(IV)
 Each dose of
 medication administered, with a copy of the physician's order for
 medication.

(V)
 Ongoing
 communication with physicians prescribing psychoactive and/or control
 medication to clients receiving Opioid Maintenance Therapy services.

(VI)
 Ongoing communication with Obstetrics
 and Gynecology physicians providing medical care to pregnant women receiving
 Opioid Maintenance Therapy services.

20.
 Support Systems: The entity shall
 develop, maintain and document implementation of written policies and
 procedures that define the process utilized to provide client access to support
 services.
(i)
 Support services shall include,
 at a minimum:
(I)
 Linkage with or access to
 psychological, medical and psychiatric consultation.

(II)
 Linkage with or access to emergency
 medical and psychiatric care.

(III)

 Linkage with or access to evaluation and ongoing primary medical
 care.

(IV)
 Ability to conduct or
 arrange for appropriate laboratory and toxicology tests.

(V)
 Direct affiliation with or coordination
 through referral to more and less intensive levels of care.

(ii)
 The entity shall maintain up-to-date,
 written Memoranda of Understanding, collaborative agreements or referral
 agreements with support systems.

21.
 Staffing: 
 
(i)
 Program Sponsor: The Level I-O Program
 shall have a program sponsor who shall be an Alabama Licensed Practitioner of
 the Healing Arts with at least two (2) years supervised work experience in a
 substance related disorders treatment program. 
 
(I)
 The entity shall provide written
 documentation of the program sponsor's responsibilities and the processes
 through which they are implemented, which shall, at a minimum, include: 
 
I.
 Ensure compliance with all Federal, State
 and local laws and regulations regarding the use of Opioid agonist treatment
 medications in the treatment of Opioid addiction.

II.
 Assume responsibility for all Level I-O
 Program employees, including all practitioners, agents, or other persons
 providing medical, rehabilitative, or counseling services at the
 program.

III.
 Assign duties of the
 program director.

IV.
 Meet the
 qualifications of a staff member and be included in the listing of personnel
 authorized access to the medication unit where he/she has access to the
 medication unit.

(ii)
 Program Director: The Level I-O Program
 shall have a full-time program director.
(I)

 The Opioid Maintenance Therapy Program director shall be: 
 
I.
 An Alabama licensed Registered Nurse,
 Nurse Practitioner, Physician, or Physician's Assistant, who has two (2) years
 direct care substance related disorders treatment experience, or

II.
 An individual with a master's degree in a
 behavioral health related field and at least two (2) years direct care
 substance use disorders treatment experience.

(II)
 The entity shall provide written
 documentation of the program director's responsibilities and the processes
 through which they are implemented, which shall include, at a minimum: 
 
I.
 Manage the day to day operation of the
 program as according to duties delegated by the program sponsor.

II.
 Maintain regular office hours, which
 coordinate with the operation of the program.

III.
 Be readily accessible to the State
 Opioid Treatment Authority.

(iii)
 Medical Director: The Level I-O Program
 shall have a medical director who shall be a physician who is licensed to
 practice in the State of Alabama and who has a minimum of one (1) year
 experience in the treatment of Opioid dependency. 
 
(I)
 The entity shall provide written
 documentation of the medical director's responsibilities and the processes
 through which they are implemented, which shall, at a minimum, include: 
 
I.
 Administration of all Level I-O medical
 services performed by the program.

II.
 Ensure that the Level I-O Program
 complies with all applicable federal, state and local laws and regulations
 relative to medical care.

III.

 Attend weekly staffings with counselors, or document in the client record
 alternative and equivalent supervisory contact on a weekly basis. 
 
A.
 When the medical director is unable to
 attend a weekly staffings, the entity must date the occurrence and provide
 written documentation of how equivalent supervisory contact was accomplished,
 e.g., by phone, electronic correspondence, etc.

IV.
 Maintain ongoing communication with
 clients' physicians regarding the prescription of psychoactive and/or control
 medication during Opioid Maintenance Therapy, and to coordinate client care in
 regard to other medical needs.

V.

 Maintain ongoing communication with Obstetrics and Gynecology physicians when
 providing Opioid Maintenance Therapy services to pregnant women.

VI.
 Perform client physical examinations
 prior to dosing and provide thorough documentation of each client's Opioid
 dependency at the time of admission.

VII.
 Perform annual client physical
 examinations.

VIII.
 Authorize: 
 
A.
 All initial dose orders.

B.
 All dose and phase changes.

C.
 All take-home medications.

D.
 All changes in frequency of take-home
 medications.

E.
 Opioid withdrawal
 protocols.

IX.
 Delegate
 responsibility for medical care and procedures to other Opioid Maintenance
 Therapy Program physicians and physician extenders.

(II)
 The entity shall provide written
 documentation that the Level I-O Program's medical director, or a staff
 physician supervised and assigned by the medical director, is physically
 present in the clinic a minimum of two (2) hours per week for each fifty (50)
 clients enrolled in the program.

(iv)
 Pharmacist: The Level I-O Program shall
 have an Alabama licensed pharmacist on its staff. 
 
(I)
 The entity shall provide written
 documentation of the pharmacist's responsibilities and the processes through
 which they are implemented, which shall, at a minimum, include: 
 
I.
 Prepare all take-home
 medication.

II.
 Conduct, at a
 minimum, an annual physical drug inventory.

III.
 Assist in the development of program
 policies and procedures governing medication administration, dispensing, use
 and security.

(v)
 Nursing Personnel: The entity shall have
 an adequate number of Alabama licensed nurses to assure that all medications
 utilized during Opioid Maintenance and Withdrawal Therapy are administered in
 compliance with Alabama Board of Nursing regulations. 
 
(i)
 Supervise and delegate responsibilities
 to the Licensed Practical Nurses (LPNs) on staff.

(ii)
 There shall be a Registered Nurse (RN)
 or Licensed Practical Nurse (LPN) on site during all hours of the Level I-O
 Program's operation.

(vi)

 Clinical Supervision: The entity shall have a clinical director who shall
 provide routine clinical supervision of each Level I-O Program employee who
 provides treatment and recovery support services.

(vii)
 All direct care personnel shall have
 the qualifications as a qualified paraprofessional to provide the specific
 services delineated in the entity's program description for this level of
 care.

(viii)
 The entity shall
 document the daily availability of an adequate number of personnel to sustain
 the Level I-O Program as delineated in its operational plan and the rules
 specified, herein.

(ix)
 All clients
 will be assigned to the caseload of a primary counselor. The caseload of each
 primary counselor shall not exceed forty (40) individuals.

(x)
 The entity shall document the daily
 availability of the medical director, or a physician under the supervision and
 authority of the medical director, during medication dispensing and clinic
 operating hours, either in person or by telephone.

(xi)
 The entity shall establish a written
 protocol for notifying the State Opioid Treatment Authority, within forty-eight
 (48) hours, of any replacement or other change in the status of the program
 sponsor or medical director.

22.
 Training. The entity shall provide
 written documentation that:
(i)
 All Level I-O
 Program personnel complete the core training curriculum, as specified in Rule
 
580-9-44-.02
(3)
.

(ii)
 The entity shall provide written
 documentation that all clinical and medical services staff in a Level I-O
 Program receive training during the initial twelve (12) months employment and
 develop basic competencies in the following areas: 
 
(I)
 Opioid addiction treatment
 methodologies.

(II)
 Regulatory
 requirements for Opioid addiction treatment.

(III)
 Biopsychosocial dimensions of alcohol
 and drug use disorders.

(IV)

 Motivational and engagement strategies.

(V)
 Pharmacotherapy for Opioid
 dependency.

(VI)
 ASAM Patient
 Placement Criteria.

(VII)

 Assessment of and service planning to address biopsychosocial needs of
 individuals with Opioid dependency and related disorders.

(iii)
 Physicians who dispense methadone and
 other Opiate replacement drugs must receive a minimum of eight (8) hours of
 training each year relevant to Opioid Maintenance Therapy approved by SAMHSA
 and the State Opioid Treatment Authority.

23.
 Service Intensity: The entity shall
 develop, maintain and document implementation of written policies and
 procedures relative to Level I-O service intensity, which shall, at a minimum,
 include the following specifications:
(i)
 The
 dose and intensity of Level I-O Treatment Services shall be established on the
 basis of the unique assessed needs of each client served.

(ii)
 The program shall demonstrate
 appropriate staffing to provide core counseling services. 
 
(I)
 Issues identified through the assessment
 and ongoing reassessment process must be addressed directly in a therapeutic
 setting or referred to an appropriate, qualified entity.

(II)
 If no clinical services are indicated
 for a client, appropriate identification shall be documented in the clinical
 record.

(III)
 In no case shall
 counseling services be scheduled less frequent than one session (individualized
 or group) per month.

24.
 Length of Service: The entity shall
 provide written documentation that the duration of treatment in each Level I-O
 Program shall vary as determined by:
(i)
 The
 severity of the client's illness.

(ii)
 The client's ability to comprehend the
 information provided and use that information to implement treatment strategies
 and attain treatment goals.

(iii)

 The appearance of new problems that require another level of care.

(iv)
 The client's desire to continue
 treatment.

Notes

Ala. Admin. Code
 r. 
580-9-44-.29

New Rule: Filed January 26,
 2012; effective 
3/1/2012
.

Amended by
 
Alabama
 Administrative Monthly Volume XLI, Issue No. 04, January 31,
 2023
, eff. 
3/17/2023
.

Adopted by
 
Alabama
 Administrative Monthly Volume XLII, Issue No. 12, September 30,
 2024
, eff. 
9/18/2024
; expires 120 days,
 
1/16/2025

 (Emergency).

Author:
 Substance Abuse Services Division

Statutory Authority:

Code of Ala.
 1975
, §
 
22-50-11
.

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