For the past year, the New York State Office of Addiction Services and Supports (OASAS) has implemented a new division among its pillars of prevention, treatment, and recovery services. The newly formed Division of Harm Reduction seeks to bring both the harm reduction philosophy and its practical strategies to the continuum of care for addiction services in NYS. Harm reduction is an evidence-based approach that is critical to empowering people who use drugs (PWUD) and equipping them with the life-saving tools and information to create any positive change. Harm reduction may not be entirely new to OASAS and many of its partners, however, the institutionalization and broad implementation of harm reduction is a considerable departure and leap forward from the history of substance use and addiction services and treatment in New York. Rooted in the Temperance Movement of the 1800’s, abstinence has been the leading approach to substance use and substance use treatment. Abstinence was also seen as the only acceptable policy towards substance use nationwide. The draconian Rockefeller Drug Laws of 1974, saw among other things, the penalty of life imprisonment for possessing two ounces or more of heroin, cocaine, and cannabis. A system of punishment was created as opposed to a system of support and empowerment.
Practical in its approach, harm reduction was created to save lives and reduce disease transmission at the height of an epidemic. Harm Reduction works to empower PWUD and their communities to live healthy, self-directed, and purpose-filled lives. It accepts that each person is the expert of their own lives, and that recovery is individualized. It recognizes that abstinence from substances is not an actual requirement for full participation in society. With over 30 years of evidence-based, harm reduction services throughout NYS, mainstream embrace of the practice has been met with controversy and resistance from the very beginning.
Harm reduction approaches have been employed for decades, but really took shape in the 1980’s. The first cases of what would later become known as AIDS, were reported in the United States in 1981. Observed for the first time in a cluster of people who inject drugs (PWID) and gay men, harm reduction became central in the fight to keep people alive. By 1984, half of all new HIV cases, the virus that led to AIDS, were among the PWID community. Organized by harm reductionists, syringe services programs (SSPs) were successful at preventing transmission of the virus and keeping people alive. SSPs were proven to be effective prevention programs that provided a range of services, including substance use treatment and overdose prevention education.
Launched in 1988 as a pilot project to allow for the establishment of an SSP to prevent the transmission of HIV, NYC SSPs were immediately met with controversy. The idea of providing PWID with the tools to use their substances was seen, and often still is, as “enabling their drug use”. Opponents of harm reduction often believe that harm reduction is simply enabling PWUD rather than helping them use it more safely and decreasing potential harms. Due to the controversial nature of the pilot, it was shut-down after 14 months. Though it was short-lived, it demonstrated that HIV risk behaviors were modified by SSP participants. Also, in 1988 a congressional ban prohibiting the use of federal funds for SSPs was instituted. This ban was lifted in 2016 by the Obama administration. This legislation allowed federal funds to be used for SSP expenses, but still not for purchasing the syringes.
It wasn’t until 1993 that SSPs were legalized throughout NYS. Since their adoption 30 years ago as a comprehensive harm reduction approach, new HIV cases among the injection drug use (IDU) community have decreased dramatically. Prior to the legalization of SSPs, IDU accounted for nearly half of all new HIV cases in NYS. Specifically, IDU was the risk factor for 57% of all new HIV cases among Blacks, 62% of new cases among Hispanics, and 58% of new cases among women in NYS. In 2022, new cases of HIV among the IDU community is only ~3%. Although SSPs have proven benefits, it is still a challenge to garner widespread support for their implementation.
The focus of many of the early harm reduction programs was HIV prevention. Founded during the crisis of the 1980-90s, harm reduction was proven to be an effective prevention strategy. With the fall of new HIV cases, came the rise of the opioid crisis in New York State. Since 2010, the number of overdose deaths involving any opioid have increased in New York. This sharp rise in fatal overdoses signaled that a shift was needed in how the community responded.
Naloxone, approved in 1971 by the Food and Drug Administration (FDA) to treat opioid overdoses, is a medication used to reverse or reduce the effect of opioids. Pioneered by the harm reduction community, NYS passed a life-saving law in 2006, making it legal in NYS for non-medical persons to administer naloxone to another individual to prevent an opioid overdose from becoming fatal. This comprehensive approach allowed for the provisions of naloxone and overdose prevention education at all SSPs and SUD treatment programs by becoming a registered Opioid Overdose Prevention Program (OOPP). Currently, over 850 registered programs offer training and provide naloxone to trained individuals.
Highly effective and safe, naloxone has saved thousands of lives from overdose. An opioid antagonist, naloxone can reverse the life-threatening respiratory depression associated with opioid overdose and block the effects of the opioids temporarily. As the opioid epidemic has continued to ravage communities throughout NYS, naloxone administration and distribution has become even more crucial. While naloxone is highly effective at reversing an opioid overdose, it is only effective if it is available and given at the time of the overdose. Research shows that when naloxone and comprehensive overdose education are available to PWUD and the community, overdose deaths decrease in those communities. In 2023, OASAS made naloxone available to all New Yorkers free of charge, expanding access to a life-saving medication.
Another core component of comprehensive harm reduction programs is the engagement of PWUD into SUD treatment services, including the initiation of medication for addiction treatment (MAT). There are only three FDA approved medications for opioid use disorder (MOUD). Buprenorphine, an opioid partial agonist, is considered a first line treatment for OUD. Buprenorphine normalizes brain anatomy and physiology, relieves physiological opioid cravings, and normalizes body functions without the negative and euphoric effects of the opioids used previously. Buprenorphine is associated with a ~50% reduced all-cause and opioid-related mortality in PWUD.
In 2002, buprenorphine became the first opioid agonist medication to treat OUD that can be prescribed or dispensed outside of an opioid treatment program (OTP). This fundamentally shifted who could treat individuals with OUD and how PWUD could engage in care. While this expanded who could prescribe buprenorphine, there were still barriers in place that prevented many from engaging in treatment. The Substance Abuse and Mental Health Services Administration (SAMHSA) initially required that clinicians acquire a Data-2000 “X” Waiver to prescribe buprenorphine for the treatment of OUD. The removal of the “X” Waiver, in 2023, allowed for any clinician with a valid DEA registration for controlled medication to prescribe buprenorphine, increasing access to buprenorphine for all those in need.
Like SSPs before it, MOUD has not been fully embraced by the addiction community. Many falsely believe that MOUD is replacing one addiction with another addiction. To be in “recovery,” one must fully abstain from all substances, including medications to treat the disorder itself. In October 2022, OASAS changed the regulations that oversee all SUD outpatient services to read “The Program shall provide FDA approved medications to treat substance use disorder to an existing patient or prospective patient seeking admission to an Office certified program in accordance with all federal and state rules and guidance issued by the Office.” The shift away from total abstinence signified the continued embrace of harm reduction throughout the continuum of addiction services in NYS.
Building on the elimination of the “X” Waiver, the state launched the Buprenorphine Assistance Program (BUPE-AP). BUPE-AP will assist eligible uninsured or underinsured New Yorkers with the costs of buprenorphine for MOUD. BUPE-AP will allow SUD providers to enroll in the program to roll-out the benefit state-wide. With this project OASAS continues to support expansions to harm reduction services across NYS, including increasing and expanding access to life-saving MOUD.
In 2022, according to CDC provisional data, 6.358 New Yorkers died from an overdose, more than any year on record. From the very beginning, harm reduction has been at the forefront of a public health crisis. Harm reduction works to incorporate a spectrum of strategies that includes safer use, managed use and abstinence. It ultimately recognizes the rights of PWUD and aims to empower any positive change. It is hopefully through this embrace of harm reduction that we can finally turn the tides of this epidemic.
Mary Brewster, MSW, is Associate Commissioner, Division of Harm Reduction, and Dr. Kelly Ramsey, MD, MPH, MA, FACP, DFSAM, is Chief of Medical Services at New York State Office of Addiction Services and Supports (OASAS).
The New York State Office of Addiction Services and Supports (OASAS) oversees one of the nation’s largest substance use disorder systems of care with approximately 1,700 prevention, treatment and recovery programs serving over 680,000 individuals per year. OASAS is the single designated state agency responsible for the coordination of state-federal relations in addiction services. Our mission is to improve the lives of New Yorkers by leading a comprehensive system of addiction services for prevention, treatment, harm reduction and recovery. Our approach is responsive, data-driven, person-centered, and prioritizes equity. Please visit us at https://oasas.ny.gov/.
