Substance Use Harm Reduction in Medical Care (1/22/25) | Substance Use Care

Substance Use Harm Reduction in Medical Care (1/22/25) | Substance Use Care
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NEW YORK STATE DEPARTMENT OF HEALTH AIDS INSTITUTE
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Purpose of This Guideline
Date of current publication:
January 22, 2025
Lead author:
Judith Griffin, MD
Writing group:
Susan D. Whitley, MD; Timothy J. Wiegand, MD, FACMT, FAACT, DFASAM, DFSAM; Sharon L. Stancliff, MD; Anne K. Monroe, MD, MSPH; Brianna L. Norton, DO, MPH; Narelle Ellendon, RN; Charles J. Gonzalez, MD; Christopher J. Hoffmann, MD, MPH, MSc, FACP
Committee:
Substance Use Guidelines Committee
Date of original publication:
August 29, 2019
This guideline on harm reduction was developed by the New York State Department of Health AIDS Institute (NYSDOH AI) to guide primary care clinicians and other clinical practitioners in integrating harm reduction principles into the treatment and care of adults with substance use and substance use disorders (SUDs).
Goals
By providing evidence-based guidelines on treatment of substance use and SUDs, the NYSDOH AI and the Substance Use Guidelines Committee aim to increase the availability of treatment in general medical settings. With this guideline, the committee aims to promulgate a harm reduction approach to medical care of patients who use substances or have SUDs and to:
Promote adoption of practical harm reduction strategies to reduce the negative consequences associated with drug and alcohol use.
Increase awareness and use of NYSDOH and local/regional harm reduction resources.
Support healthcare clinicians in recognizing and addressing the effects of stigma, which can pose a barrier to individuals seeking substance use treatment and harm reduction services.
Role of primary care clinicians:
Primary care clinicians in New York State play an essential role in identifying substance use in patients, counseling patients about risky substance use, and expanding access to evidence-based treatment. SUDs are chronic conditions that can be successfully managed in primary care or other outpatient settings.
In the clinical context, harm reduction is an approach based on the use of practical strategies to reduce the negative consequences associated with substance use. It is founded on respect for and the rights of those individuals who use drugs (adapted from the
National Harm Reduction Coalition
). A harm reduction approach promotes positive changes beyond abstinence, which may include reducing substance use and using safely to reduce disease acquisition and transmission, and emphasizes the avoidance of coercion, discrimination, and bias in the clinical care of people with SUDs.
The NYSDOH AI and this committee strongly advocate a harm reduction approach in the care of all individuals who use substances, including those with a diagnosed SUD. The recommendations are based on emerging evidence and the extensive clinical experience of this committee.
Racial and Ethnic Disparities
Studies conducted before the COVID-19 pandemic documented racial or ethnic disparities in access to evidence-based opioid use disorder (OUD) treatment
Goedel, et al. 2020
Lagisetty, et al. 2019
and opioid overdose mortality rates
Friedman, et al. 2022
Larochelle, et al. 2021
. These disparities in access to treatment and mortality appear to have worsened during the COVID-19 pandemic
Kariisa, et al. 2022
Nguyen, et al. 2022
Khatri, et al. 2021
Because people of color experience a disproportionate level of harm associated with substance use and repercussions related to use, it is essential to expand access to evidence-based harm reduction services and treatment for people of color who use substances. Clinicians can work directly with patients and their families and regular social contacts to provide naloxone and other harm reduction services when indicated and refer patients to appropriate community-based organizations for further support.
Harm Reduction During the COVID-19 Pandemic
The COVID-19 pandemic had devastating consequences for people who use substances, with unprecedented increases in overdose deaths
CDC(b) 2024
Kouimtsidis, et al. 2021
Krawczyk, et al. 2021
. In the United States, in the 12 months ending in April 2021, the Centers for Disease Control and Prevention reported 75,673 opioid-related overdose deaths compared with 56,064 deaths in the preceding 12-month period
CDC 2021
. In 2019, 2,939 overdose deaths (14.9 per 100,000 population) occurred among New York State residents, which is nearly triple the rate in 2010
NYSDOH 2021
. Preliminary 2020 data indicate the rate continues to increase; in New York State (excluding New York City), there were 2,521 (22.5 per 100,000 population) opioid-related deaths
NYSDOH 2022
New harm reduction interventions were implemented in response to COVID-19. For example, under the federal COVID Public Health Emergency (PHE), telemedicine was used to initiate medication for OUD treatment, thus expanding and protecting access to evidence-based treatment
Jones, et al. 2022
Tofighi, et al. 2022
Wang, et al. 2021
. The ability to initiate and continue medication for OUD treatment via telehealth after the conclusion of the COVID PHE remains unclear at this time;
PHE exemptions for telehealth have been extended through 2025
while new regulations are under review. Other harm reduction services implemented in response to the pandemic include home and mail-order delivery programs for naloxone distribution and syringe exchange.
Trauma-Informed Care
Trauma is more common among people with an SUD
Bartholow and Huffman 2021
Karsberg, et al. 2021
Zarse, et al. 2019
, and this population is more likely to experience trauma in healthcare settings
Aronowitz and Meisel 2022
Simon, et al. 2020
. The effect of trauma on the health and well-being of individuals and communities is gaining visibility and attention
Center for Youth Wellness 2024
Robert Wood Johnson Foundation 2024
CDC 2023
. Trauma results from an event
series of events, or set of circumstances that is experienced (or perceived) by an individual as physically or emotionally harmful or life-threatening and that has lasting adverse effects on the individual’s functioning and mental, physical, social, emotional, or spiritual well-being
SAMHSA 2014
. Historical trauma refers to cumulative traumatic experience and associated harms extending over an individual life span and across generations. In a trauma-informed approach, clinicians recognize the signs of trauma and avoid retraumatizing patients.
RESOURCES
Substance Abuse and Mental Health Services Administration:
Trauma-Informed Care in Behavioral Health Services (TIP 57)
Centers for Disease Control and Prevention:
Trauma-Informed Care Learning Series
New York State Trauma-Informed Network & Resource Center
Center for Health Care Strategies:
Trauma-Informed Care Implementation Resource Center
Implementing Substance Use Harm Reduction
RECOMMENDATIONS
Implementing Substance Use Harm Reduction
For patients who use substances, whether or not they are engaged in SUD treatment, clinicians should continue to offer medical care, including HCV and HIV screening and treatment, HIV PrEP, and HIV PEP, as indicated. (A3)
Clinicians should offer or refer for harm reduction counseling and services, including counseling on safer substance use. (A3)
To assist in harm reduction and treatment planning, clinicians should ask patients about all of the substances they use, methods of use, use networks, and the role and effects of substance use in their daily lives. (A3)
Clinicians should collaborate with patients to set specific harm reduction/treatment goals, recognizing that goals other than full abstinence, such as reduced or safer use, are acceptable. (A3)
To reduce harms associated with drug injection, clinicians should refer patients to an
NYS Authorized Syringe Exchange Site
and advise patients against sharing and reusing equipment given the associated risks. (A2)
Opioid Overdose Prevention
Clinicians should educate patients on the risks of drug overdose, especially fentanyl overdose, discuss risk reduction strategies, and counsel patients to:
Assume that all illicitly manufactured opioids contain fentanyl or other high-potency synthetic opioids and that stimulants and counterfeit pills may contain these agents. (A3)
When possible, test drugs with fentanyl and xylazine test strips or other drug-checking systems [a]. (A3)
Try to avoid using drugs alone [b]. (A3)
Start with a small amount when using any drug. (A3)
Carry NLX, learn how to use it to reverse an opioid overdose, and encourage friends and contacts to do the same. (A2)
Clinicians should offer or refer patients to a local or online resource for fentanyl and xylazine test strips and instructions on their use. (B3)
Clinicians should ensure that patients have access to NLX: prescribe the 4 mg NLX nasal spray formulation with refills or refer the patient to a local or online resource [c]. (A2)
Pharmacologic Treatment
When indicated, clinicians should offer pharmacologic treatment for patients with an SUD [d]. (A3)
See NYSDOH AI guidelines
Treatment of Opioid Use Disorder
and
Treatment of Alcohol Use Disorder
Clinicians should continue to prescribe SUD treatment for patients who continue or resume use. (A3)
Abbreviations:
HCV, hepatitis C virus; NLX, naloxone; PEP, post-exposure prophylaxis; PrEP, pre-exposure prophylaxis; SUD, substance use disorder.
Notes:
See
MATTERS > Harm Reduction
to order fentanyl and xylazine test strips (for an individual or organization).
Suggest, for instance, that individuals might arrange for someone to check in on them or may use phone- or web-based apps, such as
Never Use Alone Inc.
(877-696-1996).
See
Box 1: Harm Reduction Resources in New York State (January 2025)
Office-based services; medically managed, monitored, or supervised withdrawal and stabilization; outpatient services; opioid treatment programs (e.g., methadone programs); and residential treatment. For information on treatment availability in New York State, see the
OASAS Treatment Availability Dashboard
Harm Reduction Approach
Substance use or SUDs, whether treated or not, do not preclude delivery of primary care services. Regardless of a patient’s desire to engage in treatment for substance use as part of their medical care, every clinic visit is an opportunity to provide primary care with attention to screening for sexually transmitted and injection drug use-associated diseases, including HIV and HCV, vaccinations, and sexual health services. See NYSDOH AI guidelines:
HIV Testing
Hepatitis C Virus Screening, Testing, and Diagnosis in Adults
PrEP to Prevent HIV and Promote Sexual Health
PEP to Prevent HIV Infection
Working with a patient who uses substances to implement an appropriate harm reduction/treatment plan involves balancing many factors, and choice may be limited by availability and other practical considerations. Some individuals may perceive substance use to be more helpful or pleasurable than harmful. Asking about and understanding the perceived benefits of substance use can help the clinician identify other ways for the patient to obtain the same or similar benefits and tailor a successful treatment plan.
Harm reduction/treatment goals:
Traditionally, SUD treatment providers have considered abstinence the primary goal of treatment, but this approach is evolving. Changing the pattern of or reducing substance use has measurable health benefits and contributes to increased function, even if the individual continues to use substances
Charlet and Heinz 2017
Lea, et al. 2017
Collins(a), et al. 2015
Collins(b), et al. 2015
Gjersing and Bretteville-Jensen 2013
. See
ASAM: Engagement and Retention of Nonabstinent Patients in Substance Use Treatment: Clinical Consideration for Addiction Treatment Providers
For some individuals with a SUD, the use of other substances can reduce the use of the more problematic substance. There is increasing interest in the use of cannabis, cannabidiol, and other substances to reduce the compulsion to use opioids
Chye, et al. 2019
Socías, et al. 2017
. Choosing cannabis may be a harm reduction strategy for some patients who use opioids because fewer risks are associated with cannabis use.
One example of harm reduction counseling is to review any potential interactions between the substance(s) a patient uses and medications taken for other conditions and dispel misinformation about drug-drug interactions
Kalichman(a), et al. 2022
. In studies among individuals with HIV, intentional nonadherence to ART is associated with the belief that alcohol and other drugs interact with ART medications
Kalichman(a), et al. 2022
Kalichman(b), et al. 2022
El-Krab and Kalichman 2021
. If no significant interactions exist, patients should be encouraged to take all medications as prescribed even when using substances.
Based on individual patient needs and priorities and available clinical resources, clinicians should offer or refer patients for harm reduction services. Services may include primary or specialty medical care, education and counseling on safer drug use, development of an overdose safety plan including access to NLX, provision of sterile drug use equipment, provision of
fentanyl and xylazine test strips
or other options for drug checking, and referrals to social support resources.
Sterile syringes and needles and other drug equipment:
Harm reduction includes the provision of or referral for sterile needles and syringes
Bowman, et al. 2013
. Sharing injection equipment can transmit bloodborne diseases, such as HIV and HCV; in the United States, injection drug use is the leading cause of HCV infection
CDC(a) 2024
. Syringe access has been associated with dramatic reductions in HIV transmission; as syringe exchange was expanded in New York City, HIV seroincidence decreased to 1 per 100 person-years from 4 per 100 person-years
Des Jarlais and Carrieri 2016
. Syringe exchange has also been associated with reductions in HCV transmission
Saab, et al. 2018
Des Jarlais, et al. 2005
. Unsterile injection equipment is associated with soft tissue infections, including methicillin-resistant
Staphylococcus aureus
(MRSA),
Candida albicans
, and
Staphylococcus aureus
Hartnett, et al. 2019
. It is also important for individuals who use drugs to have access to safe and sterile supplies beyond syringes, including alcohol swabs, ascorbic acid, sterile water, sterile cookers, sterile filters, tourniquets, straight stems, push sticks, brass screens, bowl pipes, mouthpieces, foil, paper straws, and benzalkonium wipes.
KEY POINTS
Xylazine, a nonopioid sedative used in animals, has increasingly been found in the nonprescription drug supply, frequently mixed with fentanyl.
Known as “tranq” or “tranq dope” when combined with heroin or fentanyl, xylazine has severe central nervous system depressant effects, and use may cause skin and soft tissue wounds, including ulceration.
For more information and harm reduction strategies, see the NYSDOH fact sheet
Xylazine: What Clinicians Need to Know
Counsel patients to test drugs for xylazine. Online sources for xylazine test strips include
MATTERS
(for New York State residents and programs, no charge) and
BTNX
; on-site drug testing is available at some
NYSDOH Drug User Health Hubs
Opioid Overdose Prevention
Clinicians should provide patient education on the risks of overdose and discuss strategies to reduce overdose risk. See Box 1, below, for resources in New York State and the NYSDOH resource
Your health and life matter. Build a safety plan
Fentanyl:
Fentanyl, a synthetic opioid, is a common and often unidentified additive to heroin and other drugs such as cocaine, methamphetamine, and counterfeit pills that look like various opioid analgesics and benzodiazepines
Colon-Berezin, et al. 2019
. Because fentanyl is much more potent than heroin, it increases the likelihood of a fatal opioid overdose. Clinicians should advise individuals who use drugs, both opioids and other drugs, on how to avoid an overdose: assume all products sold as heroin or other opioids will contain fentanyl and that stimulants and counterfeit pills may contain fentanyl, check drugs before use with a fentanyl test strip, avoid using alone, start with a small amount, carry NLX to reverse opioid overdoses, and avoid mixing drugs. If patients do use alone, counsel them to arrange for someone to check in with them; check-ins can be scheduled using phone- and web-based apps, such as
Never Use Alone Inc
KEY POINTS
Individuals who use stimulants may be exposed to fentanyl or other high-potency synthetic opioids through concurrent use of opioids or through illicitly manufactured stimulants that contain these agents.
Advise patients that all illicitly manufactured opioids will contain synthetic opioids and nonprescription stimulants and counterfeit pills may contain these agents.
Offer NLX,
fentanyl and xylazine test strips
, and other harm reduction strategies to patients who use nonprescription stimulants.
Drug checking:
Testing drugs with specialized equipment at a test site or with fentanyl test strips provides the chemical content of drugs before use. Some
NYSDOH Drug User Health Hubs
offer drug checking with on-site gas chromatography-mass spectrometry machines that separate and detect chemical compounds.
Fentanyl test strips may promote safer use practices because individuals who are aware that drugs contain fentanyl may opt to use a smaller amount, change the mode of administration, or not use. Clinicians should discuss fentanyl test strips with patients who use opioids and other substances, such as methamphetamines, because of the prevalence of fentanyl in the nonprescription drug supply.
False-positive results erroneously showing the presence of fentanyl can occur when substances have been cut with high levels of diphenhydramine, methamphetamine, or 3,4-methylenedioxy-methamphetamine (MDMA)
Lockwood, et al. 2021
. Clinicians should counsel patients on how to use fentanyl test strips correctly, particularly when testing methamphetamines; if dilution is not performed correctly when testing methamphetamines, false-positive results may result. For more information on using fentanyl test strips, see NYC Health
How to Test Your Drugs Using Fentanyl Test Strips
Naloxone:
Clinicians should prescribe or ensure access to NLX for individuals at risk of experiencing or witnessing an opioid overdose. As an opioid antagonist, NLX displaces other opioids from opioid receptors but does not cause opioid effects and does not have the potential for misuse. Clinicians should also encourage patients’ family members, friends, or other regular contacts to have NLX on hand and be trained to use it for reversing opioid overdose. The nasal spray formulation of NLX (“Narcan”) can be administered by laypeople and bystanders to reverse an opioid overdose safely and effectively. In New York State, intranasal NLX is covered by Medicaid, and the NYSDOH
Naloxone Co-payment Assistance Program
(see Box 1, below) covers a portion of the cost for patients with private insurance who have a copay for NLX.  NLX is also distributed free of charge and regardless of insurance status by
NYSDOH-Registered Opioid Overdose Prevention Programs
The nasal spray formulation of NLX is typically prescribed and administered as a 4 mg dose. In 2021, the U.S. Food and Drug Administration (FDA) approved an
8 mg dose of NLX nasal spray
and a
5 mg prefilled syringe of NLX
for intramuscular or subcutaneous injection to treat opioid overdose, but few clinical data are available that clarify when a higher dose or alternative administration method is indicated
FDA 2021
. A recent study of NLX 4 mg or 8 mg administration by New York State police first responders found that the same number of doses were administered regardless of formulation
Payne, et al. 2024
. In this study, there was no dose-related difference in survival, but the 8 mg dose was associated with more than twice the risk of withdrawal symptoms than the 4 mg dose. Ninety-nine percent of persons who received NLX, regardless of dose, survived.
The use of stimulants, either alone or in combination with other substances including opioids, has been increasing
Han, et al. 2021
, and no FDA-approved pharmacologic treatment is available specifically for stimulant use disorder. Individuals who use stimulants may be unknowingly exposed to fentanyl. As such, it is essential to offer NLX, fentanyl test strips, and other harm reduction strategies to patients who use nonprescription stimulants.
Overdose prevention centers (or sites)
In December 2021, the first overdose prevention centers (OPCs) in the United States were opened in New York City. As of January 2025, staff at the 2 New York City sites have reversed 1,696 overdoses, and a total of 5,804 individuals have used the sites; see
OnPoint NYC
OPCs, also known as “supervised injection facilities” or “supervised consumption sites” have been opened in 11 countries and are increasingly recognized as an evidence-based and cost-effective harm reduction intervention
Samuels, et al. 2022
. At an OPC, people can use drugs that they have obtained elsewhere under medical supervision. Sterile injection supplies are available, and staff are trained to monitor for overdose and administer oxygen, NLX, and other first-response care as needed. Additional medical and social services may be offered, including referrals to SUD treatment or other indicated services
ICER 2021
. Notably, an opinion study in the United States showed higher levels of support for “overdose prevention sites” than “supervised consumption sites” (45% vs. 29%), suggesting that using the term OPS (or OPC) may be preferred to foster public support
Valencia, et al. 2021
Kennedy, et al. 2019
Barry, et al. 2018
No fatal overdose has been reported in an OPC. Evidence demonstrates that OPCs are associated with improved outcomes, including reductions in overdose mortality
ICER 2021
Levengood, et al. 2021
Kral, et al. 2020
Kennedy, et al. 2019
, injection-related infections
Valencia, et al. 2021
, and injection risk behaviors, without increasing crime in the surrounding communities.
Abbreviations:
MATTERS, Medication for Addiction Treatment & Electronic Referrals; OASAS, Office of Addiction Services and Supports; OTC, over-the-counter; STI, sexually transmitted infection.
Notes:
New York State Medicaid allows 11 refills.
New York State Medicaid allows 5 refills.
Box 1: Harm Reduction Resources in New York State (January 2025)
Naloxone (NLX)
Clinicians can prescribe NLX as a 4 mg or 8 mg nasal spray with refills for patients at risk of experiencing or witnessing an overdose [a]. NLX is also available in a prefilled syringe for injection.
NLX may be purchased OTC as a 3 mg or 4 mg nasal spray
Naloxone is covered by state Medicaid. Coverage among private insurers varies due to the OTC status of some products. To use insurance for OTC NLX in a retail store, patients must go to the store pharmacy, not the check-out line.
All pharmacies in New York State may dispense NLX without a patient-specific prescription to individuals who are at risk of an overdose or their family members or friends.
The NYSDOH
Naloxone Co-payment Assistance Program (N-CAP)
covers up to $40.00 of any co-payment for NLX obtained through insurance.
NYSDOH-Registered Opioid Overdose Prevention Programs
, which include syringe exchange and drug treatment programs and the New York State Department of Corrections and Community Supervision, distribute free NLX.
Mail-order:
NLX is available through
NEXT Distro
and
MATTERS
(for New York State residents and programs, no charge)
Resources:
OASAS Harm Reduction:
Virtual Opioid Overdose Rescue Training
NYC Health:
Overdose Prevention Resources for Providers
National Harm Reduction Coalition:
Understanding Naloxone
PrescribeToPrevent.org
Sterile needles and syringes
Clinicians can prescribe sterile needles and syringes with refills [b].
Licensed pharmacies, healthcare facilities, and healthcare providers can sell or furnish hypodermic needles or syringes to individuals aged ≥18 years without a patient-specific prescription; see NYSDOH
Expanded Syringe Access Program: Overview of the Law and Regulations
Syringe exchange sites:
As of January 2025, there are more than 30 syringe exchange programs in New York State; see
NYS Authorized Syringe Exchange Sites
Some sites offer individual and peer harm and risk reduction counseling; HIV, STI, and hepatitis counseling, screening, and testing; behavioral interventions; mental health counseling; opioid overdose prevention training; safety planning; aftercare for overdose; and care management. Syringe exchange sites can also evaluate individuals aged <18 years to determine whether syringes are needed.
Second-tier syringe exchange programs (STSEP):
Service providers, including community-based organizations, local health departments, accredited hospitals, and other accredited medical facilities, who have registered with New York State and added harm reduction services and supplies to existing services; see
NYS Authorized Syringe Exchange Sites
. Harm reduction services include client-centered education, counseling, and provision of sterile syringes and sharps containers. For more information, contact the NYSDOH
Office of Drug User Health
Drug checking
Drug checking service:
NYSDOH
Drug Checking
NYC Health
Alcohol and Drug Use Services
Fentanyl test strips:
Clinicians cannot prescribe fentanyl test strips, but programs can purchase the strips for distribution, and federal funds can be used for the purchase.
Online sources include
MATTERS
(for New York State residents and programs, no charge),
DanceSafe
, and
BTNX
. Some
NYS Authorized Syringe Exchange Sites
may provide fentanyl test strips and other drug-checking systems.
See NYC Health:
How to Test Your Drugs Using Fentanyl Test Strips
Xylazine test strips:
Clinicians cannot prescribe xylazine test strips, but programs can purchase the strips for distribution, and federal funds can be used for the purchase.
Online sources include
MATTERS
(for New York State residents and programs, no charge) and
BTNX
Drug User Health Hubs
These New York State locations provide healthcare, mental health services, and pharmacologic treatment tailored to meet the needs of people who use drugs, especially those who inject drugs. Services may be provided on-site or through facilitated linkage to culturally competent care and treatment services. See NYSDOH
Drug User Health
Pharmacologic Treatment for Substance Use Disorder
A range of effective pharmacologic treatments is available for several SUDs, including alcohol
Jonas, et al. 2014
Rösner, et al. 2010
Overman, et al. 2003
, tobacco
Anthenelli, et al. 2016
Piper, et al. 2009
, and opioid use disorders
Lee, et al. 2018
Mattick, et al. 2014
. Clinicians should discuss with patients the pharmacologic treatments and different treatment settings available and help them understand the benefits and risks. In New York State, most drug treatment programs licensed by the Office of Addiction Services and Supports are mandated to provide pharmacotherapy when indicated
OASAS 2022
. Some patients may misunderstand or have biases against pharmacologic treatment, so it may be helpful to continue these discussions over time.
Because the patient may benefit from treatment, clinicians should not deny or discontinue SUD treatment if a patient continues to or returns to use
Gjersing and Bretteville-Jensen 2013
. In 2017, the FDA issued a
drug safety communication
urging caution in denying methadone or buprenorphine when patients are taking benzodiazepines, because the risk of opioid overdose is higher with no treatment than the risks of continuing medications.
SUD is a chronic health condition that requires long-term management, including pharmacologic treatment
Saitz, et al. 2013
, which should be continued for as long as it is beneficial to the patient. Patients may opt to discontinue medication, but clinicians should encourage resumption without suggesting or implying that discontinuation of pharmacologic treatment is the preferred approach.
KEY POINT
If the criminal justice system, child welfare services, or other similar entities discontinue an individual’s OUD treatment plan, clinicians can advocate for continuation of their patient’s pharmacologic treatment plan.
Individualized follow-up during outpatient SUD treatment:
Ongoing, regular follow-up is essential for support, encouragement, and modification of the treatment plan as needed.
Follow-up within 2 weeks of treatment initiation allows tailoring of the treatment plan according to individual needs (e.g., change in dose of pharmacologic treatment, addition of support services).
As patients stabilize on treatment, monthly or at least quarterly follow-up allows for ongoing evaluation to ensure that the patient’s goals are being met.
As with all diseases and disorders, patients who have a SUD may present with medical complexities beyond a clinician’s expertise. Adolescents may require specialty care, as may individuals who are pregnant or who have co-occurring psychiatric disorders. When individual patient factors complicate diagnosis and treatment, local and national resources are available for consultation and referral. For opioid-related issues, see
Providers Clinical Support System
or NYSDOH AI
Provider Directory
Avoiding Substance Use-Associated Discrimination
RECOMMENDATIONS
Avoiding Substance Use-Associated Discrimination
Clinicians should examine their assumptions and decisions for any personal biases that may affect their ability to provide effective care for individuals who use substances. (A3)
Clinicians and other staff interacting with patients should use neutral terms to describe all aspects of substance use and avoid language that perpetuates stigma (see
Box 2: Changing the Language of Substance Use
). (A2)
Stigma in the Healthcare Setting
Substance use-related stigma may prevent individuals from seeking or receiving treatment and harm reduction services
Tsai, et al. 2019
. In particular, people who use substances during pregnancy face significant stigma and may fear accessing medical care or other services as a result
Schiff, et al. 2022
Wakeman, et al. 2021
. Stigma among clinicians against people who use substances has been well documented
Stone, et al. 2021
Tsai, et al. 2019
van Boekel, et al. 2013
. Clinician bias has been associated with health disparities and can have profoundly negative effects
FitzGerald and Hurst 2017
Hall, et al. 2015
. In particular, the stigma associated with substance use may increase the risk of overdose, although the exact mechanism for this association is not well defined. In 1 study, enacted stigma (discrimination) was associated with an increased risk of opioid overdose but internalized stigma was not. This finding may suggest that enacted stigma could contribute to risk behaviors, such as using quickly or in multiple locations to avoid detection
Latkin, et al. 2019
Cruz, et al. 2018
It is often challenging for clinicians to recognize and set aside personal biases and to address biases with peers and colleagues. Consciously or unconsciously, negative or stigmatizing assumptions are often made about patient characteristics, such as race, ethnicity, gender, sexual orientation, mental health, and substance use
Avery, et al. 2019
van Boekel, et al. 2013
Livingston, et al. 2012
. Individuals who use substances may also be stigmatized by assumptions about substance use and criminal behavior. For more information, see the resources listed below.
RESOURCES
Attitudes Toward Individuals With Mental Illness and Substance Use Disorders Among Resident Physicians
, Avery JD, Taylor KE, Kast KA, et al.
Prim Care Companion CNS Disord
2019;21(1):18m02382.
Some Advice for Physicians and Other Clinicians Treating Minorities, Women, and Other Patients at Risk of Receiving Health Care Disparities
, White A, Stubblefield-Tave B.
J Racial Ethn Health Disparities
2017;4(3):472-79.
Avoiding Unintended Bias: Strategies for Providing More Equitable Health Care
, Van Ryn M.
Minn Med
2016;99(2):40-43, 46.
To acknowledge and address stigma, clinicians are advised to consciously change their substance use-related vocabulary to avoid stigmatizing terms, to use neutral medical terms, and to help colleagues and staff adopt neutral language (see Box 2, below). For example, the term “dirty urine test” elicits a more negative reaction toward a patient than the more accurate and neutral term “opiate-positive test result”
Kelly and Westerhoff 2010
. Patients may choose to use stigmatizing words in describing themselves, but clinicians and staff should strive to use language that is respectful of the individual and easy to understand.
Notes:
For additional terms and definitions, see
Addictionary
For discussion on stigmatizing information disseminated in the media, see
Changing the Narrative
Box 2: Changing the Language of Substance Use [a,b]
Neutral Term
Stigmatizing Term
Substance use
Substance abuse
Use of nonprescription medication or drug
Illicit drug use
Pharmacologic treatment
Medication-assisted treatment
A person who uses drugs, alcohol, or substances
Drug addict, drug abuser, alcoholic, junkie, crackhead, tweaker, etc.
A person who formerly used drugs or alcohol
A person who got clean
Negative or positive toxicology results
Clean or dirty toxicology results
A recurrence of use or return to use
Relapse
Legal Protections for Individuals With Substance Use Disorder
The New York State Human Rights Law (NYSHRL) and the American With Disabilities Act (ADA) protect individuals with disabilities from discrimination in the workplace and housing. Under the NYSHRL and ADA, individuals taking prescribed medical treatment for SUD and those in recovery from SUD are considered disabled; for patients with OUD, see
The Americans with Disabilities Act and the Opioid Crisis: Combating Discrimination Against People in Treatment or Recovery
. The NYSHRL and the ADA
exclude
from protection individuals who are currently using illegal drugs.
Employers and housing providers are prohibited from discriminating against individuals with disabilities under the NYSHRL. Employers are prohibited from denying a job opportunity to a qualified individual, terminating an employee because of a disability, and making inquiries about an individual’s disability, which includes questions about prescribed medical care for SUD. Employers are to provide reasonable accommodations to assist disabled people in performing their job functions. It is unlawful for housing providers to refuse to house or discriminate against a tenant because they are taking medical treatment for SUD or are in recovery from SUD.
Information about these protections and enforcement of the NYSHRL can be found at the
New York State Division of Human Rights
All Recommendations
ALL RECOMMENDATIONS: SUBSTANCE USE HARM REDUCTION IN MEDICAL CARE
Implementing Substance Use Harm Reduction
For patients who use substances, whether or not they are engaged in SUD treatment, clinicians should continue to offer medical care, including HCV and HIV screening and treatment, HIV PrEP, and HIV PEP, as indicated. (A3)
Clinicians should offer or refer for harm reduction counseling and services, including counseling on safer substance use. (A3)
To assist in harm reduction and treatment planning, clinicians should ask patients about all of the substances they use, methods of use, use networks, and the role and effects of substance use in their daily lives. (A3)
Clinicians should collaborate with patients to set specific harm reduction/treatment goals, recognizing that goals other than full abstinence, such as reduced or safer use, are acceptable. (A3)
To reduce harms associated with drug injection, clinicians should refer patients to an
NYS Authorized Syringe Exchange Site
and advise patients against sharing and reusing equipment given the associated risks. (A2)
Opioid Overdose Prevention
Clinicians should educate patients on the risks of drug overdose, especially fentanyl overdose, discuss risk reduction strategies, and counsel patients to:
Assume that all illicitly manufactured opioids contain fentanyl or other high-potency synthetic opioids and that stimulants and counterfeit pills may contain these agents. (A3)
When possible, test drugs with fentanyl and xylazine test strips or other drug-checking systems [a]. (A3)
Try to avoid using drugs alone [b]. (A3)
Start with a small amount when using any drug. (A3)
Carry NLX, learn how to use it to reverse an opioid overdose, and encourage friends and contacts to do the same. (A2)
Clinicians should offer or refer patients to a local or online resource for fentanyl and xylazine test strips and instructions on their use. (B3)
Clinicians should ensure that patients have access to NLX: prescribe the 4 mg NLX nasal spray formulation with refills or refer the patient to a local or online resource [c]. (A2)
Pharmacologic Treatment
When indicated, clinicians should offer pharmacologic treatment for patients with an SUD [d]. (A3)
See NYSDOH AI guidelines
Treatment of Opioid Use Disorder
and
Treatment of Alcohol Use Disorder
Clinicians should continue to prescribe SUD treatment for patients who continue or resume use. (A3)
Avoiding Substance Use-Associated Discrimination
Clinicians should examine their assumptions and decisions for any personal biases that may affect their ability to provide effective care for individuals who use substances. (A3)
Clinicians and other staff interacting with patients should use neutral terms to describe all aspects of substance use and avoid language that perpetuates stigma (see
Box 2: Changing the Language of Substance Use
). (A2)
Abbreviations:
HCV, hepatitis C virus; NLX, naloxone; PEP, post-exposure prophylaxis; PrEP, pre-exposure prophylaxis; SUD, substance use disorder.
Notes:
See
MATTERS > Harm Reduction
to order fentanyl and xylazine test strips (for an individual or organization).
Suggest, for instance, that individuals might arrange for someone to check in on them or may use phone- or web-based apps, such as
Never Use Alone Inc.
(877-696-1996).
See Box 1: Harm Reduction Resources in New York State (January 2025).
Office-based services; medically managed, monitored, or supervised withdrawal and stabilization; outpatient services; opioid treatment programs (e.g., methadone programs); and residential treatment. For information on treatment availability in New York State, see the
OASAS Treatment Availability Dashboard
Shared Decision-Making
Download Printable PDF of Shared Decision-Making Statement
Date of current publication:
August 8, 2023
Lead authors:
Jessica Rodrigues, MS; Jessica M. Atrio, MD, MSc; and Johanna L. Gribble, MA
Writing group:
Steven M. Fine, MD, PhD; Rona M. Vail, MD; Samuel T. Merrick, MD; Asa E. Radix, MD, MPH, PhD; Christopher J. Hoffmann, MD, MPH; Charles J. Gonzalez, MD
Committee:
Medical Care Criteria Committee
Date of original publication:
August 8, 2023
Rationale
Throughout its guidelines, the New York State Department of Health (NYSDOH) AIDS Institute (AI) Clinical Guidelines Program recommends “shared decision-making,” an individualized process central to patient-centered care. With shared decision-making, clinicians and patients engage in meaningful dialogue to arrive at an informed, collaborative decision about a patient’s health, care, and treatment planning. The approach to shared decision-making described here applies to recommendations included in all program guidelines. The included elements are drawn from a comprehensive review of multiple sources and similar attempts to define shared decision-making, including the Institute of Medicine’s original description [
Institute of Medicine 2001
]. For more information, a variety of informative resources and suggested readings are included at the end of the discussion.
Benefits
The benefits to patients that have been associated with a shared decision-making approach include:
Decreased anxiety [
Niburski, et al. 2020
Stalnikowicz and Brezis 2020
Increased trust in clinicians [
Acree, et al. 2020
Groot, et al. 2020
Stalnikowicz and Brezis 2020
Improved engagement in preventive care [
McNulty, et al. 2022
Scalia, et al. 2022
Bertakis and Azari 2011
Improved treatment adherence, clinical outcomes, and satisfaction with care [
Crawford, et al. 2021
Bertakis and Azari 2011
Robinson, et al. 2008
Increased knowledge, confidence, empowerment, and self-efficacy [
Chen, et al. 2021
Coronado-Vázquez, et al. 2020
Niburski, et al. 2020
Approach
Collaborative care:
Shared decision-making is an approach to healthcare delivery that respects a patient’s autonomy in responding to a clinician’s recommendations and facilitates dynamic, personalized, and collaborative care. Through this process, a clinician engages a patient in an open and respectful dialogue to elicit the patient’s knowledge, experience, healthcare goals, daily routine, lifestyle, support system, cultural and personal identity, and attitudes toward behavior, treatment, and risk. With this information and the clinician’s clinical expertise, the patient and clinician can collaborate to identify, evaluate, and choose from among available healthcare options [
Coulter and Collins 2011
]. This process emphasizes the importance of a patient’s values, preferences, needs, social context, and lived experience in evaluating the known benefits, risks, and limitations of a clinician’s recommendations for screening, prevention, treatment, and follow-up. As a result, shared decision-making also respects a patient’s autonomy, agency, and capacity in defining and managing their healthcare goals. Building a clinician-patient relationship rooted in shared decision-making can help clinicians engage in productive discussions with patients whose decisions may not align with optimal health outcomes. Fostering open and honest dialogue to understand a patient’s motivations while suspending judgment to reduce harm and explore alternatives is particularly vital when a patient chooses to engage in practices that may exacerbate or complicate health conditions [
Halperin, et al. 2007
].
Options:
Implicit in the shared decision-making process is the recognition that the “right” healthcare decisions are those made by informed patients and clinicians working toward patient-centered and defined healthcare goals. When multiple options are available, shared decision-making encourages thoughtful discussion of the potential benefits and potential harms of all options, which may include doing nothing or waiting. This approach also acknowledges that efficacy may not be the most important factor in a patient’s preferences and choices [
Sewell, et al. 2021
].
Clinician awareness:
The collaborative process of shared decision-making is enhanced by a clinician’s ability to demonstrate empathic interest in the patient, avoid stigmatizing language, employ cultural humility, recognize systemic barriers to equitable outcomes, and practice strategies of self-awareness and mitigation against implicit personal biases [
Parish, et al. 2019
].
Caveats:
It is important for clinicians to recognize and be sensitive to the inherent power and influence they maintain throughout their interactions with patients. A clinician’s identity and community affiliations may influence their ability to navigate the shared decision-making process and develop a therapeutic alliance with the patient and may affect the treatment plan [
KFF 2023
Greenwood, et al. 2020
]. Furthermore, institutional policy and regional legislation, such as requirements for parental consent for gender-affirming care for transgender people or insurance coverage for sexual health care, may infringe upon a patient’s ability to access preventive- or treatment-related care [
Sewell, et al. 2021
].
Figure 1: Elements of Shared Decision-Making
Health equity:
Adapting a shared decision-making approach that supports diverse populations is necessary to achieve more equitable and inclusive health outcomes [
Castaneda-Guarderas, et al. 2016
]. For instance, clinicians may need to incorporate cultural- and community-specific considerations into discussions with women, gender-diverse individuals, and young people concerning their sexual behaviors, fertility intentions, and pregnancy or lactation status. Shared decision-making offers an opportunity to build trust among marginalized and disenfranchised communities by validating their symptoms, values, and lived experience. Furthermore, it can allow for improved consistency in patient screening and assessment of prevention options and treatment plans, which can reduce the influence of social constructs and implicit bias [
Castaneda-Guarderas, et al. 2016
].
Clinician bias has been associated with health disparities and can have profoundly negative effects [
FitzGerald and Hurst 2017
Hall, et al. 2015
]. It is often challenging for clinicians to recognize and set aside personal biases and to address biases with peers and colleagues. Consciously or unconsciously, negative or stigmatizing assumptions are often made about patient characteristics, such as race, ethnicity, gender, sexual orientation, mental health, and substance use [
Avery, et al. 2019
van Boekel, et al. 2013
Livingston, et al. 2012
]. With its emphasis on eliciting patient information, a shared decision-making approach encourages clinicians to inquire about patients’ lived experiences rather than making assumptions and to recognize the influence of that experience in healthcare decision-making.
Stigma:
Stigma may prevent individuals from seeking or receiving treatment and harm reduction services [
Tsai, et al. 2019
]. Among people with HIV, stigma and medical mistrust remain significant barriers to healthcare utilization, HIV diagnosis, and medication adherence and can affect disease outcomes [
Turan, et al. 2017
Chambers, et al. 2015
], and stigma among clinicians against people who use substances has been well-documented [
Stone, et al. 2021
Tsai, et al. 2019
van Boekel, et al. 2013
]. Sexual and reproductive health, including strategies to prevent HIV transmission, acquisition, and progression, may be subject to stigma, bias, social influence, and violence.
SHARED DECISION-MAKING IN HIV CARE
As prevention and treatment modalities in HIV care expand (i.e., vaccines, barriers, injectables, implants, on-demand therapies), it is important for clinicians to ask patients about their goals for prevention and treatment rather than assume that efficacy is the primary factor in patient preference [
Sewell, et al. 2021
].
The shared decision-making approach to clinical care enhances patient knowledge and uptake of new technologies and behavioral practices that align with the patient’s unique preferences and identity [
Sewell, et al. 2021
], ensures that the selection of a care plan is mutually agreed upon, and considers the patient’s ability to effectively use and adhere to the selected course of prevention or treatment.
Resources and Suggested Reading
In addition to the references cited below, the following resources and suggested reading may be useful to clinicians.
RESOURCES
Minnesota Shared Decision-Making Collaborative
AHRQ:
The SHARE Approach: 5 Essential Steps of Shared Decision-Making
Medline Plus:
Shared Decision-Making
NICE:
Shared Decision-Making
PCORI:
The Significance of Shared Decision-Making
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Updates, Authorship, and Related Guidelines
Updates, Authorship, and Related Guidelines
Date of original publication
August 29, 2019
Date of current publication
January 22, 2025
Highlights of changes, additions, and updates in the January 22, 2025 edition
Box 1: Harm Reduction Resources in New York State: Text on availability of naloxone and resources for drug-checking updated
Intended users
Primary care clinicians and other practitioners in New York State with adult patients who use substances
Lead author
Judith Griffin, MD
Writing group
Susan D. Whitley, MD; Timothy J. Wiegand, MD, FACMT, FAACT, DFASAM, DFSAM; Sharon L. Stancliff, MD; Anne K. Monroe, MD, MSPH; Brianna L. Norton, DO, MPH; Narelle Ellendon, RN; Charles J. Gonzalez, MD; Christopher J. Hoffmann, MD, MPH, MSc, FACP
Author and writing group conflict of interest disclosures
There are no author or writing group conflict of interest disclosures.
Committee
Substance Use Guidelines Committee
Developer and funder
New York State Department of Health AIDS Institute (NYSDOH AI)
Development process
See Guideline Development and Recommendation Ratings Scheme, below.
Related NYSDOH AI guidelines
Guidelines
Hepatitis C Virus Screening, Testing, and Diagnosis in Adults
PEP to Prevent HIV Infection
PrEP to Prevent HIV and Promote Sexual Health
Treatment of Alcohol Use Disorder
Treatment of Opioid Use Disorder
Podcast
Viremic—Cases in HIV
Guideline Development and Recommendation Ratings
Guideline Development: New York State Department of Health AIDS Institute Clinical Guidelines Program
Program manager
Clinical Guidelines Program, Johns Hopkins University School of Medicine, Division of Infectious Diseases. See
Program Leadership and Staff
Mission
To produce and disseminate evidence-based, state-of-the-art clinical practice guidelines that establish uniform standards of care for practitioners who provide prevention or treatment of HIV, viral hepatitis, other sexually transmitted infections, and substance use disorders for adults throughout New York State in the wide array of settings in which those services are delivered.
Expert committees
The NYSDOH AI Medical Director invites and appoints committees of clinical and public health experts from throughout New York State to ensure that the guidelines are practical, immediately applicable, and meet the needs of care providers and stakeholders in all major regions of New York State, all relevant clinical practice settings, key New York State agencies, and community service organizations.
Committee structure
Leadership: AI-appointed chair, vice chair(s), chair emeritus, clinical specialist(s), JHU Guidelines Program Director, AI Medical Director, AI Clinical Consultant, AVAC community advisor
Contributing members
Guideline writing groups: Lead author, coauthors if applicable, and all committee leaders
Disclosure and management of conflicts of interest
Annual disclosure of financial relationships with commercial entities for the 12 months prior and upcoming is required of all individuals who work with the guidelines program, and includes disclosure for partners or spouses and primary professional affiliation.
The NYSDOH AI assesses all reported financial relationships to determine the potential for undue influence on guideline recommendations and, when indicated, denies participation in the program or formulates a plan to manage potential conflicts. Disclosures are listed for each committee member.
Evidence collection and review
Literature search and review strategy is defined by the guideline lead author based on the defined scope of a new guideline or update.
A comprehensive literature search and review is conducted for a new guideline or an extensive update using PubMed, other pertinent databases of peer-reviewed literature, and relevant conference abstracts to establish the evidence base for guideline recommendations.
A targeted search and review to identify recently published evidence is conducted for guidelines published within the previous 3 years.
Title, abstract, and article reviews are performed by the lead author. The JHU editorial team collates evidence and creates and maintains an evidence table for each guideline.
Recommendation development
The lead author drafts recommendations to address the defined scope of the guideline based on available published data.
Writing group members review the draft recommendations and evidence and deliberate to revise, refine, and reach consensus on all recommendations.
When published data are not available, support for a recommendation may be based on the committee’s expert opinion.
The writing group assigns a 2-part rating to each recommendation to indicate the strength of the recommendation and quality of the supporting evidence. The group reviews the evidence, deliberates, and may revise recommendations when required to reach consensus.
Review and approval process
Following writing group approval, draft guidelines are reviewed by all contributors, program liaisons, and a volunteer reviewer from the AI Community Advisory Committee.
Recommendations must be approved by two-thirds of the full committee. If necessary to achieve consensus, the full committee is invited to deliberate, review the evidence, and revise recommendations.
Final approval by the committee chair and the NYSDOH AI Medical Director is required for publication.
External reviews
External review of each guideline is invited at the developer’s discretion.
External reviewers recognized for their experience and expertise review guidelines for accuracy, balance, clarity, and practicality and provide feedback.
Update process
JHU editorial staff ensure that each guideline is reviewed and determined to be current upon the 3-year anniversary of publication; guidelines that provide clinical recommendations in rapidly changing areas of practice may be reviewed annually. Published literature is surveilled to identify new evidence that may prompt changes to existing recommendations or development of new recommendations.
If changes in the standard of care, newly published studies, new drug approval, new drug-related warning, or a public health emergency indicate the need for immediate change to published guidelines, committee leadership will make recommendations and immediate updates and will invite full committee review as indicated.
Recommendation Ratings Scheme
Strength
Quality of Evidence
Rating
Definition
Rating
Definition
Strong
Based on published results of at least 1 randomized clinical trial with clinical outcomes or validated laboratory endpoints.
Moderate
Based on either a self-evident conclusion; conclusive, published, in vitro data; or well-established practice that cannot be tested because ethics would preclude a clinical trial.
Optional
Based on published results of at least 1 well-designed, nonrandomized clinical trial or observational cohort study with long-term clinical outcomes.
2†
Extrapolated from published results of well-designed studies (including nonrandomized clinical trials) conducted in populations other than those specifically addressed by a recommendation. The source(s) of the extrapolated evidence and the rationale for the extrapolation are provided in the guideline text. One example would be results of studies conducted predominantly in a subpopulation (e.g., one gender) that the committee determines to be generalizable to the population under consideration in the guideline.
Based on committee expert opinion, with rationale provided in the guideline text.
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