David Minot, Executive Director of Mental Health News Education, the non-profit organization that publishes Behavioral Health News, interviewed Mary Brewster, Associate Commissioner for Harm Reduction at the New York State Office of Addiction Services and Supports (OASAS). The mission of OASAS is to improve the lives of New Yorkers by leading a comprehensive system of addiction services for prevention, treatment, harm reduction and recovery. In this interview, Mary discusses the importance and life-saving potential of harm reduction approaches for substance use disorders and overdose prevention.
This transcript has been lightly edited for clarity.
David Minot: Hi, and welcome to the Behavioral Health News Spotlight on Excellence series, where we feature exceptional leaders and innovative health care solutions that are raising the standards of care in the behavioral health community. My name is David Minot, and I am the Executive Director of Mental Health News Education, the nonprofit organization that publishes Behavioral Health News and Autism Spectrum News. Our mission is devoted to improving lives and the delivery of care for people living with mental illness, substance use disorder, and autism, while also supporting their families and the professional communities that serve them.
Today, we’re speaking with Mary Brewster, Associate Commissioner for Harm Reduction at the New York State Office of Addiction Services and Supports, also known as OASAS. Mary, thanks so much for being here today!
Mary Brewster: Thanks for having me. I’m excited to be here!
David: To start off our conversation, can you give me an overview of the new Division of Harm Reduction at OASAS? What is its mission and what is your role as Associate Commissioner?
Mary: Absolutely. I am shockingly coming up on my one-year anniversary at OASAS – time has flown by! I started with the agency in September 2022 and I’m the first Acting Associate Commissioner for our division. This division is brand new to our system of care, but I would be remiss to not say that harm reduction is not new to our OASAS system of care. It’s something that our providers have long practiced. But when Dr. Chinazo Cunningham, who is our Acting Commissioner, started in the beginning of 2022, one of the lenses and one of the priorities that she really was bringing with her was a focus on harm reduction. When she started in her role, this was one of the divisions that she created, taking the opportunity to recognize that harm reduction has long been happening in our continuum of care, but shining a spotlight on harm reduction and the work that we do.
Our mission is really to take harm reduction to our community, working with our over 1,700 providers throughout New York State to provide substance use services, helping them implement harm reduction, helping them understand what harm reduction is, and recognizing those opportunities to incorporate harm reduction theory and practices into their services and into their care. Not only am I working with our OASAS providers, but it’s also our OASAS system and our staff here at OASAS – getting them to understand what harm reduction is and how to talk about harm reduction and really implement it across our continuum of services. My role is to lead the division. We are now a staff of four, still a very small staff doing this work. And the division is really structured around three different pillars that we’re going to be focusing on.
The first is focused on education, technical assistance, and resources. Education is a huge part of my job and the division. What is harm reduction? How do we implement harm reduction? Again, getting out in front of the community, talking to them, doing a kind of “harm reduction 101.” This is new for many of our providers. We are setting that baseline of what harm reduction is, providing technical assistance, not only to our system of care and our substance use disorder (SUD) providers, but also to OASAS staff. We’re a state agency and we have civil service staff. Not everyone who works here comes in with a working understanding of harm reduction. WE are working with both our system of care and our staff here at OASAS and then providing resources. Harm reduction isn’t just a philosophy and a theory of care, but it’s practical resources that we provide. For example, we’ve just launched a huge campaign and project of getting naloxone, brand name Narcan, out into community, and getting fentanyl test strips and xylazine test strips out to our community. We are working to provide education on the theory of harm reduction and also give the practical tools that you need to implement harm reduction.
That’s one pillar of my division. Another is to really focus in on the regulations, structure, and culture of OASAS – really looking at our regulations that regulate substance use treatment services throughout New York State and making sure that they support harm reduction. Harm reduction is about low-threshold care and removing barriers to care – making sure that our regulations can be implemented in a harm reduction setting and can support harm reduction. It’s also thinking about our CASACs, our certified alcohol and substance use counselors, making sure that the education they receive has a focus on harm reduction and stands right alongside prevention, treatment, and recovery.
And then our third pillar is focused on special projects. This is where we get to have a lot of fun. I have a couple of initiatives that are running right now through our division and have my staff member, Cameron, working on all of those special projects to truly implement harm reduction services. And another part of my role is really incorporating harm reduction services into each bureau and division at OASAS, making sure that our prevention division has a harm reduction lens that it’s using and viewing the work through moving forward.
And then we focus on adding any of those opportunities for assessment, education, and training. This is done in a few different ways – looking at our assessment tools and making sure that our assessment tools are low threshold, that we’re only asking our participants and our clients the information that’s truly needed to be able to provide them care and providing lots of education. For the next month, I’m out of the office almost the entire time traveling around the state of New York and talking about harm reduction – what does it mean? And then we have our training opportunities. We have “Learning Thursdays” with our Chief Medical Office team to be able to work with our providers to implement harm reduction into their care settings. It’s a lot for the four of us, but we are new and we are growing. I think that’s also the really exciting piece, that it’s not often that you get to work with a state agency where you have an opportunity to create a brand-new division. We are really taking the opportunity to listen to community, discover what the community thinks our division should look like, and then responding to those needs of the community.
David: It sounds like you’ve been very busy in your first year!
Mary: Very busy, yes. I just came back from my first vacation! We’ve been doing lots of work.
David: In your own words, how do you define harm reduction, and what is its historical background?
Mary: I was very fortunate that I’m a social worker by training. I have my master’s in social work and went to a macro practice school. I’m not a clinician but have definitely worked in clinical environments. And when I was in social work school, I learned harm reduction, which is not common. That’s actually an uncommon thing to get to learn in grad school. And I was really fortunate that I learned harm reduction from Dan Bigg, a long-term harm reductionist who was known in our community as the godfather of harm reduction. Dan taught that harm reduction is any positive change. It’s really thinking about what are those behaviors that we engage in that we would like to change and make healthier. And really, it’s being able to celebrate any positive change that we happen to make. Again, really focusing on those behaviors in our life that we want to change and implementing that positive change. Again, I think it’s a theory. It’s that theory of what harm reduction is, but then it’s also very practical. You take that theory and you implement it into your work. And it’s helping your clients, your participants, your patients identify that change, helping them be the agents of change, and helping them support any change that they want to make. That’s how I learned harm reduction. Again, very simple – any positive change.
Harm reduction has a long history. I said at the beginning that the Division of Harm Reduction is new, but the philosophy is not new to our OASAS system of care. Harm reduction came to us through the HIV/AIDS epidemic in the early 80s and 90s. Harm reduction, really, in the United States was born directly out of the HIV/AIDS community. In New York State, one of the first ways that harm reduction was really legalized and embraced was through the legalization of our syringe service programs (at the time known as syringe exchange programs) that happened in 1993. And the reason that these syringe exchange programs were implemented was because we were seeing in the HIV/AIDS community that one of the most perfect ways to transmit HIV and hepatitis was through the sharing of syringes. We recognized that we needed to create behavior change around people’s injection drug use. But if they didn’t have the ability to use a clean syringe for every injection, they were going to reuse syringes and share syringes. In 1993, New York State legalized syringe exchange to ensure that if you were an injection drug user, you were able to get access to a clean syringe every single time you used and you didn’t have to share those with anymore. It was really through the HIV/AIDS community that we got harm reduction here in the United States. In other parts of the world, especially in England, they’ve been practicing harm reduction since the 1970s. It just took us a little bit longer to adopt it. But it really was during a public health crisis – an epidemic – that we were experiencing in the 80s and 90s that activists said, “What we’re currently doing isn’t working. We have to do something else. And what can we do?” And harm reduction truly was one of the answers to the problems that they had.
David: It is so interesting to learn about the history that has led to where we are with harm reduction today. What makes harm reduction services so critical right now? And are they evidence-based and proven to be effective?
Mary: As you know, we are in the midst of an opioid epidemic. In 2021 (we don’t have confirmed data for 2022 yet) across the United States, over 100,000 people died in one year of unintentional drug overdose. If COVID-19 hadn’t come along, this would have been the largest public health crisis we had ever had – the largest epidemic we would have ever had in one year. During the HIV/AIDS epidemic, it took almost 9 – 10 years to reach 100,000 deaths from HIV/AIDS. We are reaching those numbers every single year – we’re really in a crisis right now. We’re in a drug poisoning and an overdose crisis. Right now in New York State, and this is a really sobering statistic that I think is really important, one person dies every five and a half hours of a drug overdose. When you come into New York City, those numbers are even worse – it’s one every three hours. When I started working in New York State or in New York City specifically in 2017, that statistic was one person every eight hours. The problem is only getting worse. More people are dying. And I think when you’re in a community and you see that kind of loss of life, you have to take a look around and say, “We have to do something differently. What we have historically been doing is clearly not enough. We have to look for all ways and opportunities to implement any positive change to help people live another day.” And I think that’s why harm reduction is so important right now.
A huge component of harm reduction is really removing as many barriers as we possibly can to get an individual engaged into care. An example of that is in my division where we’re funding 15 organizations throughout the state to implement a low threshold buprenorphine project. Buprenorphine is a medication for opioid use disorder. It’s really the gold standard of medication for addiction treatment. It used to be that there were many barriers that a person had to overcome in order to gain access to a life-saving medication for opioid use disorder. And so, part of this project is focused on how we can remove those barriers. How can we have a person present to one of our programs and say, I have opioid use disorder and I’m ready to start medication for addiction treatment today? And how can they then leave that appointment with a prescription in hand to start that medication? That’s new and revolutionary for us. It used to be that if a person was prescribed buprenorphine and they have a toxicology screening come back and it shows that it’s positive for cocaine, they were disengaged from care. Their medication was taken away from them because they were not abstaining from all substances. And we have to recognize that this isn’t a requirement for gaining access to medication. I was on a call this morning where we were discussing this – would you do that to a person who had diabetes? Would you cut them off from care if their A1C numbers were not improving? If they weren’t adhering to the nutrition plan that you gave them? No. That’s a moment to be able to wrap around even more services to them and say, “Ok, you have the medication. What else is going on and how can we help you?” I think that’s where we are right now. That’s why harm reduction is so important and why we should embrace it.
Harm reduction is absolutely evidence-based. Again, syringe exchange programs started in the United States or in New York City in 1993. They had been happening on the West Coast since 1988. It’s been over 30 years now, almost 40 years. That’s terrifying. It doesn’t feel like it’s been that long ago. Almost 40 years of evidence to show that syringe exchange programs are effective at decreasing HIV and hepatitis C rates. We know that for a fact. Medication for opioid use disorder. Again, those gold star medications, – buprenorphine and methadone – they’re associated with at least a 50% decrease in mortality. No other medication that we have does that for a disease state. That’s evidence-based. We know these medications are effective at keeping people alive. We’ve seen the peer distribution of naloxone. Naloxone is the medication that is used to reverse an opioid overdose. It’s a life-saving intervention with people who are most likely to witness their peers experience overdose. And we know that having peers distribute naloxone has led to that increase in naloxone and is not associated with an increase in substance use. We know that naloxone saturation helps drive down those overdose numbers. Because when someone is able to witness an overdose and has a life-saving medication in their hand, we know that they can save a life. I think that the research is there, and it really does show that implementing harm reduction and low-threshold services helps people engage in life-saving care.
David: You’re so right – engaging peers to save lives with naloxone is such an effective and proven method of harm reduction. How does the harm reduction approach align with existing prevention, treatment, and recovery models in the field?
Mary: The way that I think about harm reduction is as a continuum, it’s a buffet. Prevention, treatment, and recovery are all harm reduction interventions. Preventing and delaying initiation of use, that’s harm reduction. Pat Zuber-Wilson is our Associate Commissioner of Prevention and she and I work closely on what harm reduction messaging look like because prevention is all a harm reduction message. Treatment is harm reduction, right? We just talked about medication for opioid use disorder. That’s a harm reduction strategy because it is decreasing risk associated with substance use. Even if a person uses methadone only one time a week, they don’t go every day for their take-home doses, they just go one time a week. That’s one instance where we know they are using a safe substance that is regulated for them to use. And recovery is also harm reduction. Recovery is individualized – that’s something that we at OASAS have recognized for a long time. Recovery is harm reduction, recognizing of course that abstinence may not be where everyone lands on that continuum of use to abstinence, but recovery is 100% harm reduction. Again, my division doesn’t stand apart from prevention, treatment, and recovery. I stand alongside them in working to ensure that all of our services, that the common thread that we’re pulling through, are a harm reduction message and are done through a harm reduction lens.
David: Harm reduction, as you know, does have its critics and controversies. In your view, why is that? And what steps are you and OASAS taking to increase acceptance of harm reduction among both people who use drugs and service providers?
Mary: I think that there is this common misconception that harm reduction is against recovery, against treatment, and is against abstinence. That is absolutely not the case. I think what harm reductionists recognize is that we can’t mandate care to a person – that a person has to be engaged in that care – and again, recognizing that treatment and recovery has to be individualized. And that can be very controversial. People think that harm reductionists are condoning substance use, that we are encouraging people to use drugs. I would say that’s partially true. We’re not telling people to stop using drugs. What we’re encouraging is safer drug use, safer substance use.
You know, as a harm reductionist, I recognize that substances have been a part of our history forever. Think back to the Greeks and the Romans. They drank wine. Wine is a mind-altering substance and we have been drinking wine for thousands of years. Substances will always be a part of our reality and harm reduction recognizes that. We aren’t trying to eliminate substances. We’re trying to minimize any of the risks and dangers that are associated with substance use. And I think that can be very controversial when you’re talking about drugs. You know, here in the United States, we’ve done a really, really good job of demonizing substance use and demonizing people who use drugs. And we see the negative consequences of substance use, especially as we’ve criminalized substances and we’ve seen all of the arrests. I think that harm reduction is often questioned, “How can you support someone using drugs?” I’m not supporting their substance use. I’m supporting them using safely. That’s our goal, to keep people alive and to keep them safe so that if they ever decide to engage in treatment and recovery, we are there for them. I hate this phrase, but I think it’s really important: A dead person can’t recover. And that’s why harm reduction is so important to us. Again, a lot of controversy still around substance use, a lot of controversy around harm reduction. You know, in 1993 syringe exchanges became legal and they’re still controversial, even though we have all the data to show how effective they are at preventing HIV and hepatitis C, which was their intended purpose.
The way that OASAS is trying to increase acceptance of this approach is through the creation of our Division of Harm Reduction and that the philosophy of harm reduction care is something they believe in. Increasing acceptance is done through working with the OASAS provider systems. You know, I’ve told all of our providers, “Invite me into your staff meetings. I’m happy to come in and talk about what harm reduction actually is and what harm reduction isn’t.” I think it is a really important conversation, but what is harm reduction? It’s important to explain it, to take a lot of that myth out of what harm reduction is, debunk these preconceived notions, and really explain what harm reduction is from a very basic level. Explain why we’re embracing it and how a person can actually implement harm reduction services into their system of care. You need a lot of education and training.
David: You spoke earlier about the demonization of drugs and drug users. That makes me think of stigma and how the stigma around substance use is one of the biggest barriers for people seeking and receiving the help they need. How does stigma play a role in working with people who use drugs and what steps can be taken to reduce this stigma?
Mary: Yes, I think stigma is our biggest barrier to working with people who use drugs. They experience stigma everywhere. They have institutional stigma against them. There’s social stigma against them, internalized stigma, not feeling valued, not feeling self-worth because “I’m a person who uses drugs.” I come from the HIV/AIDS community. I’m very aware of stigma. It’s been something that’s followed me my entire career. I actually remember my first job interview right out of grad school and it was with an HIV/AIDS service organization. And the Executive Director asked me if I felt comfortable having the word AIDS on my resume because that’s a big black check mark on my resume that I’ve worked with HIV/AIDS.
I think stigma is especially prevalent when you’re working with the most marginalized communities, and people living with HIV/AIDS are some of the most marginalized. People who use drugs are some of the most marginalized members of our community as well. Stigma follows them everywhere they go. And stigma absolutely kills people because it stops them from coming into our door for care.
I think some of the steps that we can take is the language we use – making sure that the language that we use is not stigmatizing people. You’ll notice I don’t call people “substance abusers.” I don’t call people “addicts.” That’s stigmatizing language. It is important to make sure that we use person-first language such as people who use drugs, a person who uses drugs, and not using words like junkie, right? That’s such a stigmatizing word. And also not using the words clean and dirty. I think a lot of times we use what I consider to be slang when we’re talking about your toxicology screenings and we should really be using really clinical language. That’s a clinical test that a person takes. It’s not clean or dirty, it’s positive or negative. Their urine was positive for, their urine was negative for. I think that’s really important because if a person is clean, that implies that they used to be dirty and people aren’t dirty, we’re not dirty people.
We really think the language that we use matters, the way that we talk about people who use drugs matter, and just recognizing people’s humanity and recognizing that people, regardless of whether they use substances or not, are worthy of dignity and respect is a good place to start. It takes a lot of work. We all have a bias, right? And I think it’s as service providers, it’s recognizing what our own bias is and being able to talk about that bias and work through it. Behavioral Health News is not one of them, but the media in general has done a really good job of stigmatizing people who use drugs. If you look at the New York Post any day of the week, you will see horrible headlines referring to people who use drugs as junkies. That language is so inflammatory to use. I understand it sells newspapers, but when we hear that language it should be called out. I think it’s really important to correct people’s language and explain that this is the reason we don’t say addict. There’s a reason that we say “a person with a substance use disorder.” I think that’s a huge way that anyone can address stigma and work to de-stigmatize drugs and people who use drugs.
David: I agree that the language we use is so important. We are always looking to avoid the use of stigmatizing language in Behavioral Health News. Can you provide some specific examples of how harm reduction is successfully being implemented in New York State to save lives?
Mary: Absolutely. New York State is leading the way in implementing innovative harm reduction and addiction services. Colleagues from across the country contact us to learn about the programs we have successfully rolled out. Some impactful initiatives we have undertaken since 2006 include creating opioid overdose prevention programs. Through these programs, even those without medical training like myself can access the medication naloxone. Naloxone reverses opioid overdoses and saves lives. In 2006 we began building these programs, and we have since expanded them dramatically. Now OASAS is making naloxone widely available to providers in our health systems and directly to New Yorkers in need. People can easily obtain naloxone through a website where they enter their information and we ship the medication to them. We have also made fentanyl test strips available statewide to both residents and providers. This is crucial because fentanyl is involved in over 80% of fatal overdoses. The test strips allow people who use drugs to test their substances for fentanyl contamination. If positive, they can make informed decisions to reduce their risk of overdose. By getting naloxone and test strips into the hands of those who need them most, we empower New Yorkers to take actions that save lives.
I’m proud that even though state government can be slow to act, we quickly pivoted when the drug xylazine began appearing in the supply. We rapidly made xylazine test strips available to people who use drugs. This allows them to test for contaminants beyond just opioids. Our partners at the New York City Department of Health and Mental Hygiene and the state Office of Drug User Health were also quick to establish drug checking programs. These allow people to bring in substances to be tested so they can make informed choices about use.
Another lifesaving area we have decades of experience in is syringe service programs. Our partners at the Department of Health oversee these programs, which have operated in New York for over 30 years. We now have over 30 syringe exchange programs across the state, reaching New York City and remote areas alike.
I’m originally from Kansas where shockingly there was not one statewide syringe exchange program as of 2002. Meanwhile we have over 30 programs serving New Yorkers. Expanding these services remains a point of pride.
Additionally, we have expanded medication for addiction treatment, known as MAT, into all state jails and prisons. Incarcerated individuals with opioid use disorder now have access to these potentially lifesaving medications. Ensuring connections to care so they can continue their MAT upon release is also a priority.
I will briefly note the overdose prevention centers run by OnPoint in NYC. These are not overseen or funded by OASAS or the Department of Health. And I should make sure to mention that Governor Hochul has not taken a position on overdose prevention centers. These are not legally operated, but a tenet of harm reduction is you do what’s right, not what’s allowed. These are the only two overdose prevention centers in the nation. They’re located in East Harlem and Washington Heights, which have some of the highest rates of fatal overdose deaths in the city, where one person is dying every three hours. They recognized there was a need for these services, and so they implemented the overdose prevention centers, which are new to the United States, but not new globally. There are over six countries that have overdose prevention centers. In their first year and a half of operation, they reversed over 1,000 overdoses. That’s 1,000 lives that they saved in one year. These centers are highly controversial, but they’re saving lives. Controversy aside, our job as service providers is to make sure that our clients are thriving, living healthy lives, and living to see another day. That’s what OnPoint is doing.
David: Wow, the impact you’re having and the number of lives you’re saving is really incredible. To wrap up, what message of hope or encouragement would you like to share with the substance use disorder community about the potential of harm reduction?
Mary: While harm reduction is not new, we are expanding its reach and ensuring it has a seat at the table. With our division’s growth and singular focus on harm reduction, I hope to see more programs statewide and more lives saved.
I’m thrilled we have a major naloxone distribution project underway, saturating communities with this lifesaving medication. If someone witnesses an overdose, they now have the tools to intervene. It seems these efforts are gaining acceptance, which is heartening.
Tragically, it took the staggering loss of life from overdoses for many to recognize the importance and urgency of harm reduction. But I’m hopeful the tide is turning. More people understand we must take action – we cannot continue business as usual. All hands are needed on deck for this work.
There’s an excellent TED Talk by the sociologist Johann Hari called Everything You Know About Addiction is Wrong. He concludes that for too long we have been singing war songs about drugs, when we should have been singing love songs to people who use drugs.
I think we are starting to embrace that mindset of leading with love and compassion. We must keep our doors open, meet people where they are, and engage them in whatever way we can to support positive changes. That is my hope, and I sincerely hope we can curb the devastation addiction has brought our communities.
David: Thank you for sharing such an inspiring and thoughtful message. It’s clear you and your team are dedicating tremendous effort to bring these ideas to fruition. Your commitment to meeting people with compassion comes through loud and clear.
Mary: I appreciate you taking the time to have this conversation. It’s been a pleasure to share details about the meaningful harm reduction initiatives happening here in New York and at OASAS. My hope is that audiences not only learn about the progress being made, but also gain a deeper understanding of the compassionate, person-centered philosophy behind our work. If we lead with an open heart and make human connections, real change is possible. Thank you again for this opportunity to discuss how we can build healthier, safer communities together.
For more information about harm reduction initiatives and resources from the New York State Office of Addiction Services and Supports (OASAS), please visit oasas.ny.gov/harm-reduction and stay tuned for our next installment of the Behavioral Health News Spotlight on Excellence Series.