New York State is on the verge of adopting ideologically significant revisions to its guidelines governing programs that treat chemical dependence. The most notable changes among the new rules: Treatment providers will be required to provide medication-assisted treatment (MAT) or make it readily accessible, and providers must guide patients toward individualized "recovery" goals rather than a blanket goal of abstinence from drug use.
Remarkably, the word "abstinence" will be scrubbed from all of the pertinent regulations.
"I pulled up our regulations and did a word search for 'abstinence,' and in all of them they mentioned abstinence, so I started to do a markup," says New York's Office of Alcoholism and Substance Abuse Services (OASAS) Chief Counsel Robert Kent. "Abstinence will not be in our regulations -- not that it can't be a goal." Although OASAS doesn't use the term "harm reduction," its recovery-oriented language and rule changes reflect harm-reduction principles. To that end, OASAS will no longer require providers to use drug testing as a clinical evaluation tool.
The comment period for the regulations in question ended in mid-February. OASAS will review the comments to see if any amendments are necessary and then move forward to formally adopt the regulations at a future date. OASAS oversees some 1,600 prevention, treatment, and recovery programs. OASAS chemical dependence treatment programs have an average daily enrollment of nearly 100,000 people and serve approximately 234,000 individuals every year.
Once upon a time, MAT -- using methadone to help people get off of heroin, for example -- was anathema to treatment providers, who instead focused single-mindedly on achieving abstinence from all addictive drugs. For the same reason, treatment providers once opposed harm reduction strategies such as syringe exchange or safe injection sites. But research has consistently shown that MAT is effective in preventing overdose and the transmission of HIV and other infectious diseases.
In the 1980s, AIDS activists changed the conversation about harm reduction and abstinence because of the disease's rapid spread among injection drug users. Today, MAT, in the form of drugs like buprenorphine, has proven an effective weapon against the U.S.'s raging opioid epidemic. Buprenorphine is the first medication to treat opioid dependency that can be prescribed or dispensed in physician's offices, which vastly expands its reach.
According to the Centers for Disease Control and Prevention, in 2017, New York State had 3,264 opioid overdose deaths, 1,201 of which were in New York City. In 2016, Suffolk County had 344 opioid deaths, the most of any New York county.
OASAS has long supported MAT and has issued clinical guidelines that reflect a harm-reduction philosophy, but until now its official chemical dependency treatment regulations have lagged behind. Kent and others believe that the revisions will send a clear signal to providers who might have been afraid of violating OASAS regulations to more readily embrace MAT and harm reduction -- and send a clear signal to providers who used the out-of-date regulations as cover to reject those approaches. "That's why I felt it was so important to remove abstinence from our rules. [Providers say], 'We've been told OASAS has it in their rules.' Don't hide behind us," Kent explains.
Tracie Gardner, vice president of policy advocacy with the Legal Action Center, supports OASAS's codification of MAT and harm reduction, and submitted written comments suggesting how they should be further strengthened. Gardner, who served as New York's assistant secretary for mental hygiene from 2015 to 2017, says that practical barriers, such as red tape and fractious insurers, have been the biggest impediments to expanding MAT, not "philosophical resistance." She believes that, because of the opioid epidemic, the "whole field is coming into that awareness" that harm reduction has a role to play, including New York's largest traditional residential treatment centers -- Samaritan Daytop Village and Phoenix House -- "that evolved in an abstinence-based atmosphere that pre-dates HIV. [They] understand and have the capacity to embrace harm reduction strategies."
Phoenix House and Samaritan declined to be interviewed about the OASAS regulatory changes. Phoenix House sent a statement saying, "We offer medication-assisted treatment at our centers and support medication-assisted treatment as a part of a person's treatment plan." Norwig Debye-Saxinger, the executive director with the Therapeutic Communities Association of New York (a state chapter of a national organization) that "represents the interests of long-term residential treatment providers," including Phoenix House and Samaritan, says that "residential communities basically think the gold standard is abstinence. It isn't maintenance." He estimates that Samaritan is the largest residential treatment facility in New York, with some 1,300 beds. Phoenix House is second largest, with 445 beds.
The AIDS service organization Housing Works "strongly supports" the OASAS regulatory proposals, but its CEO Charles King is less hopeful than Legal Action Center's Gardner about the widespread acceptance of MAT and harm reduction. Housing Works, which has long offered harm reduction–oriented substance abuse treatment to its largely low-income, unstably housed clientele, is helping cofound a new coalition called the Harm Reduction Association of New York State. The purpose of the organization is to establish best practices around harm reduction, inform the educational pipeline that trains social workers who are "steeped in traditional approaches," and create what King perceives as a counter-influence to the statewide trade association, Alcoholism and Substance Abuse Providers of New York State (ASAP).
King feels ASAP "makes noise" about endorsing harm reduction but fundamentally doesn't. "[OASAS] is influenced by the agencies it supports. If people pull it to the right, having a group pulling to fund and support more harm reduction action seemed like a worthy cause," King says. So far the other members of the Harm Reduction Association of New York State, which is in the process of drafting official materials, are the Alliance for Positive Change, Center for Optimal Living, Community Health Action of Staten Island, Exponents-ARRIVE, Housing Works, Southern Tier AIDS Program, and Washington Heights Corner Project.
ASAP Executive Director John Coppola takes issue with King's view of his organization. He acknowledges that ASAP is a "big tent" that accommodates debates about issues like safe injection sites and marijuana legalization, but he feels that its members (representing 150 programs and approximately 15 regional or statewide associations) are generally in step with the times. "Harm reduction for some people in the field had a negative connotation, and that's still the case for some, but for the most part, I think people embrace harm reduction as part of a continuum of services. I think the new regulations are catching up with that," he says, adding, "I would be hard pressed to find a single therapeutic community in the state of New York that isn't administering medication."
Luke Nasta seems to fit squarely into Coppola's description. Nasta is the CEO of Staten Island's Camelot Counseling, the borough's only residential treatment facility, which will soon expand from 70 beds to 130. Nasta sees MAT as an "appropriate" treatment tool, and he's aware from both data and experience that most people relapse multiple times on the road to recovery. "We're not all open to being injection sites, that's fair; but we're not opposed to anything that saves a life and engages people in healthy, constructive approaches to life," Nasta says.
Nonetheless, Nasta bemoans the legalization of marijuana, the medicalization of substance abuse treatment over counseling -- he "strongly objects" to calling MAT a treatment gold standard -- and the abandonment of what he sees as the ideal of abstinence. "We just believe that people should make an attempt at restoring their lives without being dependent on chemicals. If that moves us into a right-wing fanatical approach, I think that's ridiculous. We've come to a place in the world where 'abstinence' is a bad word."
David Thorpe has been a New York-based editor and freelance writer for more than two decades. He writes primarily about gay life, HIV, and pop culture. His work has appeared in, among other publications, The New York Times_,_ OUT_,_ Time Out New York_,_ New York_,_ POZ_, and_ O, the Oprah Magazine_._