Declinations

The facility has offered and will continue to offer and attempt to schedule any declined case management / care coordination, psychotherapy, counseling, and one-on-one individualized treatment-plan sessions at phase-required frequencies based on state, federal, or payor requirements; the patient may accept any of these at any time. In addition to stabilization of functioning as a goal for clients, the facility’s primary focus based on all respected national addiction organizations consensus recommendations is to improve their mortality by decreasing potential overdose and death by ensuring that any barriers to access of FDA approved MAT medication(s) is eliminated. Systematic review (meta-analysis) shows ASAM, SAMHSA, CDC, FDA/SAMHSA, Medication First / low-barrier guidance, VA/DoD, WHO, TennCare BESMART, and TN Department of Health / TDMHSAS support that buprenorphine / MAT medication should not be withheld solely because the client declines case management or care-coordination sessions [1–9,14–16]; the same organizations support that medication should not be withheld solely because the client declines psychotherapy or counseling sessions [1–9,14–16]; and ASAM, SAMHSA, federal standards, and TN OBOT rules support that medication should not be withheld solely because the client declines one-on-one individualized treatment-plan sessions, while an individualized treatment/care plan remains in the record and is updated through shared decision-making at clinical contacts and required review intervals [1–3,8,10,15–16]. Unmet session cadence after documented offer/outreach reflects patient non-participation, not failure to offer or arrange the service [15–16]. Retention in opioid agonist treatment is associated with reduced mortality [11–12]. 

1. ASAM National Practice Guideline for OUD (2020 Focused Update). Assess and offer psychosocial treatment; decline or unavailability must not preclude or delay pharmacotherapy / buprenorphine.

2. SAMHSA TIP 63 — Medications for Opioid Use Disorder. Psychosocial supports should target needs and be offered; medication should not be arbitrarily conditioned on counseling or other supports.

3. SAMHSA MAT Act / buprenorphine prescribing guidance. Counseling capacity is recommended but not required; patient refusal must not prevent buprenorphine prescribing; timing of counseling, case management, and peer support is decided with the patient.

4. FDA / SAMHSA Dear Colleague Letter (May 9, 2023). Counseling should be offered; medication must not be contingent on counseling participation.

5. SAMHSA Advisory: Low Barrier Models of Care for SUD. Avoid service-engagement preconditions; medication access should not depend on concurrent counseling or multiple mandated services.

6. Medication First principles. Individualized psychosocial services are continually offered but not required as a condition of pharmacotherapy.

7. CDC — Treating Opioid Use Disorder. Cites ASAM: declining psychosocial treatment must not preclude or delay medications for OUD.

8. 42 CFR § 8.12 (OTP standards, 2024). Care plans are patient-centered and mutually agreed; patient refusal of counseling shall not preclude MOUD.

9. VA/DoD Clinical Practice Guideline for SUD (2021). Insufficient evidence to mandate specific psychosocial add-ons beyond medical management; behavioral interventions are not a requirement to receive OUD medication.

10. WHO Guidelines for the Psychosocially Assisted Pharmacological Treatment of Opioid Dependence (2009). Psychosocial/social supports should be available; patients who do not take up the offer should not be denied pharmacological treatment.

11. Sordo et al., BMJ. 2017;357:j1550. Meta-analysis: retention in methadone or buprenorphine treatment is associated with substantially lower all-cause and overdose mortality.

12. Santo et al., JAMA Psychiatry. 2021;78(9):979-993. Meta-analysis: opioid agonist treatment associated with ~50% lower all-cause mortality during treatment versus out of treatment.

13. Carroll & Weiss, Am J Psychiatry. 2017;174:738-747 (and related POATS / Fiellin trials). Added structured counseling often yields little incremental opioid-use benefit beyond buprenorphine plus medical management for many patients.

14. TennCare BESMART Program Description. Declining counseling/psychotherapy should not preclude or delay buprenorphine; document the decline and engagement attempts.

15. TN Dept of Health / TDMHSAS Buprenorphine Treatment Guidelines (Fall 2023). Declining counseling (or lack of available counseling) should not preclude or delay pharmacotherapy; document engagement attempts.

16. Tenn. Comp. R. & Regs. 0940-05-35-.07, -.09, -.10, -.12. ITP services must be provided or offered; CM offered at phase intervals with offers charted; counseling offered/documented and ITP updated if the patient is not following through.