Two years after federal regulations permanently adopted greater flexibility for medications for opioid use disorder (MOUD), New York experts convened to discuss the benefits and challenges of take-home medications.
The annual COMPA Symposium, which was also livestreamed, was hosted by the Coalition of Medication-Assisted Treatment Providers and Advocates, a nonprofit membership organization in New York. State officials also discussed how to prevent interruptions to OUD services amid coming Medicaid eligibility and work requirement changes as part of H.R. 1.
Chinazo Cunningham, M.D., a commissioner of New York’s Office of Addiction Services and Supports (OASAS), presented on the successes the state has had thus far in expanding OUD treatment access.
“People of color in the state of New York are dying [at] the highest levels,” Cunningham began, adding that the good news is that Black New Yorkers had the largest reduction in overdose deaths from 2023 to 2025. Part of that is thanks to flexible dosing, first introduced during COVID-19 and made permanent by the Substance Abuse and Mental Health Services Administration (SAMHSA) in 2024.
This flexibility has both pros and cons, highlighted by a separate clinical panel. Allowing patients to take vital MOUD home acknowledges various social determinants that present barriers to arriving in-person on a regular basis for treatment, speakers agreed. At the same time, some cases call for extra caution, like if a patient is unstable and may be using while in treatment.
“The safety of methadone—it is a medication that we have to be very careful with,” Brett Palmer, P.A.-C, an outpatient physician assistant, said during the clinical panel. There is real risk of diversion, which patients sometimes even own up to, he said. Thus, take-home allowance “is a frequent discussion” and requires strong judgment on the part of counselors.
Myra Mathis, M.D., medical director at Strong Recovery, a certified community behavioral health clinic and opioid treatment program (OTP) in Rochester, praised the new rule while acknowledging its drawbacks. “I think it’s a positive change that medication access is no longer tied to therapy requirements,” Mathis said. But taking home MOUD also means some patients will fall behind on therapy.
To help address this, Strong Recovery added a new role of engagement specialist, whose job is to track and identify disengaged patients who have not attended individual or group therapy in three months. They can then opt into a “dispensing-only” track. That program takes into account special considerations, like access to Narcan for unstable patients and other harm reduction supplies. Patients in the track also need safety planning and screening for suicidality. The specialist meets with them at least once quarterly, which helps the program meet its billing requirements.
Incarceration access greatly improved
The state has been making progress on MOUD access and uptake across a variety of settings.
There are currently 140 outpatient methadone programs in New York. “I’m so proud of that,” Cunningham said. As the drug market continues to rapidly evolve, with fentanyl and other powerful opioids, “the role of methadone has never been more important.
Also across the state, 41 prisons and 58 jails offer all forms of MOUD. These institutions are notoriously difficult to get treatment into. Fewer than half of jails offer MOUD nationwide.
“When you’ve seen one jail, you’ve seen one jail,” Cunningham said, explaining that every county and sheriff has a different mindset. But thanks to state and community partners, MOUD access is now widespread. “There is no other state that even comes close to this,” Cunningham said.
From 2022 to 2025, the number of people receiving MOUD in New York prisons increased 7x, and those starting MOUD for the first time increased 360x. The increase was largely driven by buprenorphine access, though even the number of people on methadone doubled. In jails, from 2022 to 2024, there has also been progress. The number of people enrolled in MOUD tripled, with buprenorphine making up the bulk of MOUD use in 2024 (83%).
“Individuals who are incarcerated have among the highest rates of overdose deaths,” Cunningham said, at over 100x the risk compared to the general population. Black and Hispanic New Yorkers, who have among the highest overdose deaths in the state, are also incarcerated at much higher rates. MOUD provision in jail settings has been shown to decrease overdose risk upon release.
A big focus of Cunningham’s presentation was stimulant use disorder, which slightly more Americans have than opioid use disorder. The condition has no FDA-approved medications. “It can be frustrating for providers and programs to provide treatment,” Cunningham said. New York’s approach is to pilot a treatment modality known as contingency management, which provides incentives to reinforce positive behavior change.
“Contingency management has been studied for decades around drug use, and it’s definitely known to be effective,” Cunningham said. The reason it’s not widely used is “implementing it in the real world is very difficult.” Cunningham led a seven-year-long NIH-funded study on the modality, and even with a large annual budget, she struggled to pull it off.
The pilot in the state will begin with eight outpatient non-OTPs, set to launch next month and run for 18 months. For 12 weeks, patients with primary stimulant use disorder will come to the clinic twice a week, several days apart, and get toxicology urine testing on the spot. If it is stimulant-negative, they will get a gift card of about $15. After 12 weeks, they will come in once weekly for another 12 weeks. The financial incentive will build over time, up to $750, as allowed by SAMHSA. If they miss an appointment or relapse, the incentive restarts at $0.
“Decades of data show this is the most effective treatment for stimulant use disorder,” Cunningham reiterated. If the pilots work well, “then the goal is to really expand this statewide.”
Some regulatory changes have helped make this treatment more feasible. SAMSHSA used to cap the financial incentives at $75, not nearly enough to drive behavior change, Cunningham said. The state can also use an 1115 waiver to get reimbursed for contingency management care, though its current waiver expires in March 2027. Its renewal request is under review.
New York lays out 2027 Medicaid plan
Up to a million New Yorkers on Medicaid will be subject to new work requirements under H.R. 1 changes.
Trisha Schell-Guy, director of the Division of Program Development and Management in the Office of Health Insurance Programs, presented on the ways the state is preparing to minimize coverage loss.
There are three ways to meet the new requirements in New York. A household could have an income of at least $580 a month. A member could complete 80 hours of an approved activity in a month. Or it could be a combination of the two. Starting Jan. 1, 2027, new applicants must show compliance with the new requirements for the month before they apply. Existing members face renewal dates in March.
Certain groups are exempt from the work requirements, Schell-Guy noted, due to age or a certain condition. Groups like American Indian/Alaska Native people and foster care youth are also exempt. Additionally, there are short-term hardship exemptions, which last for six months and require an application. At the county level, these include high-unemployment areas and declared emergency or disaster areas. At the individual level, these include institutional or high-acuity care and extended travel for healthcare. The state is working to secure a short-term exemption for the Bronx as a high unemployment area, Schell-Guy noted.
For work requirements, New York is using an attestation approach for the first year—meaning members answer a short questionnaire—in recognition that it takes time to gather the necessary documentation. For 2028 and beyond, attestation will not be permitted.
“We have to use data,” Schell-Guy said, which will require collaboration between countless agencies. “There’s tons of data sources that we are trying to access here.”
Also under direction from CMS, New York has a plan for provider enrollment and re-validation. This is part of a new CMS push requiring every state to form a plan to re-validate Medicaid providers, especially those in “high-risk” areas. The state is taking a risk-tiered approach in phases. Providers considered high-risk include durable medical equipment providers, those that haven’t re-validated since the start of COVID-19, applied behavioral analysis therapy providers and home- or community-based services providers. The state’s re-validation process was on paper until 2025, proving unreliable, Schell-Guy said. Now, it is all digital.
To get the word out about coming changes, the state is staffing up its customer service center with a direct line for H.R. 1 questions; is sending member notices via a number of communication channels; has social media campaigns and TV ads; and is doing in-person events. It has also upped its number of assistors who can answer questions and help fill out applications.
“Now we expect there to be a lot of utilization of these assistors,” Schell-Guy said.