Needs Assessment - Catskills Addiction Coalition

Needs Assessment and Priority Setting
Rural Communities Opioid Response Program

Margaretville Hospital
Catskills Addiction Coalition
January 1, 2020
Grantee Organization: Margaretville Hospital/WMC Health Network

Grant Number: G25RH32953
Address: 42084 State Highway 28, Margaretville, NY 12455-2820
Service Area: Delaware, Ulster, Greene and Sullivan Counties
Project Director: Julia C. Reischel
Contributing Consortium Members and Stakeholders:
Delaware Opportunities
Central Region Prevention Resource Center
Alcohol and Drug Abuse Council of Delaware County
Delaware County Public Health
Delaware County Drug Treatment Court
Ulster County ORACLE Drug Task Force
Ulster County Sheriff
Greene County Sheriff
Delaware County Sheriff
Delaware County Mental Health
Friends of Recovery Delaware Otsego County
Samadhi Recovery Community Outreach Center
O’Connor Hospital
Delaware Valley Hospital
HealthAlliance Hospital
Delaware County Drug Use Task Force
Mark Project
Margaretville Central School
Roxbury Central School
Margaretville Hospital School Mental Health Program
Catskills Recreation Center
Pine Hill/Fleischmanns Rotary
USDA
NYS Department of Transportation
Advanced Physician Services Clinic at Margaretville Hospital
Town of Colchester
Town of Andes
Town of Davenport
Town of Stamford
Delaware County Office for the Aging
ARC of Delaware County
Ulster County Opioid Prevention Strategic Action Team
Mountainside Cares Coalition
Westchester Medical Center Health Network
Institute for Family Health
Catskill Mountain Christian Center
Maverick Family Counseling
Margaretville Hospital Auxiliary
Delaware County
Long Term Care Council
Delaware County Department of Social Services
Mountainside Residential Center
NY Connects
Rural Healthcare Alliance
Cornell Cooperative Extension of Delaware County
Delaware County Rehabilitation Support Services
SUNY Delhi School of Nursing
2
Table of Contents
Table of Contents 3
Executive Summary 7
Values 7
Target Populations 7
Key Findings 7
Priority Needs and Issues 8
A. Introduction / Background Information 10
B. Vision / Mission / Planning Values 14
C. Needs Assessment Methodologies 14
D. Overview of Results / Findings 15

a. Populations of focus 15
1. “Disconnected youth” 15
2. All area youth 17
3. Pregnant people with opioid use disorder or who have physical opioid dependence,
and newborns discharged from the hospital with neonatal withdrawal syndrome 20
4. People who use drugs and other substances in general 22
Opioid overdose death data 23
The role of fentanyl in fatal overdoses in the Catskills 26
Other drug use data 30
4. People who consider themselves in recovery from substance use 34
5. General population 35
b. Findings for service systems 37
1. Prevention 37
Primary prevention 37
Overdose Prevention: Police response and naloxone distribution and training 38
Harm reduction: Prescription take-back boxes and community sharps collection
boxes 40
2. Treatment 41
Medication Assisted Treatment in the Catskills 41
Counseling, Care Coordination and Certified Recovery Peer Advocates (CRPAs) 43
Miscellaneous issues 45
3. Recovery 46
4. Existing and possible federal, state and local resources that can be leveraged 47
c. Findings for workforce 49
3
1. Available relevant workforce 50
2. Areas of workforce shortage and gaps in workforce 50
3. Necessary competencies to provide OUD services 51
4. Estimated service demands 52
5. Evidence-based practice areas 52
6. Necessary capacity building 52
7. Resources that can support ongoing workforce development 52
d. Priority setting strategy 53
1. Priority Needs 54
2. Priority Issues 54
3. Priority Feasibility 55
4. Possible Strategies to address priorities 56
E. Discussion / Conclusion: Gaps and Constraints / Assets and Opportunities 56

Gap 1: Lack of communication and collaboration among stakeholders, service
providers and community members 56
Gap 2: No affordable public transportation in much of the region 57
Gap 3: Lack of focus on substance issues and youth, particularly “disconnected
youth” 57
Gap 4: Low number of qualified workers in Catskills region; high number of people in
recovery who need work. 58
Gap 5: The community needs a resource to go for drug use referrals, ideally with the
word “opioid” or “drug use” in the title. 58
Gap 6: Stigma causes resistance to adopting harm reduction programming 59
Gap 7: Certified recovery peer advocates (CRPAs) are not available easily and
accessibly throughout the region. 59
Gap 8: Local mental health care services don’t necessarily address substance use 60
Gap 9: No transitional affordable housing with adjacent accessible transportation
available for people in early recovery. 60
Gap 10: Cultural divides and a lack of understanding of conditions on the ground has
tied up $150,000 in opioid funding 61
Appendix A: Needs Assessment Methodologies 62
Appendix B: Living in Recovery Survey 69
Appendix C: Catskills Addiction Coalition Community Action Plan 78
Appendix D: Prioritization Strategy 85
Appendix E: Gaps and Opportunities Ranked by Priority 88

Gap 1: Lack of communication and collaboration among stakeholders, service
providers and community members. 88
Gap 2: No affordable public transportation in much of the region. 89
4
Gap 3: Lack of focus on substance issues and youth, particularly “disconnected
youth.” 90
Gap 4: Low number of qualified workers in Catskills region; high number of people in
recovery who need work. 91
Gap 5: The community needs a resource to go for drug use referrals, ideally with the
word “opioid” or “drug use” in the title. 92
Gap 6: Stigma causes resistance to adopting harm reduction programming. 93
Gap 7: Certified recovery peer advocates (CRPAs) are not available easily and
accessibly throughout the region. 94
Gap 8: Local mental health care services don’t necessarily address substance use.
95
Gap 9: No transitional affordable housing with adjacent accessible transportation
available for people in early recovery. 96
Gap 10: Cultural divides and a lack of understanding of conditions on the ground has
tied up $150,000 in opioid funding. 96
Gap 11: Local police are the first point of contact with people with substance use
problems, and yet have little understanding of addiction and no referral mechanism
to connect people who use drugs with treatment and recovery resources. 98
Gap 12: Not enough findable, accessible and affordable MAT providers in region. 99
Gap 13: Rural first responders and community members know little about naloxone
and often don’t carry it. 100
Gap 14: Little coordination between medication assisted treatment providers and
services. 101
Gap 15: Re-entry into community life from incarceration is difficult for people in
recovery. 102
Gap 16: Many patrons at the local food pantry have problems stemming from
substance use. 103
Gap 17: Pharmacists are hesitant to and/or stymied from using harm reduction
strategies. 103
Gap 18: There is unused capacity at Margaretville Hospital. 104
Gap 19: Need for data and services geared towards those infants and towards
pregnant people with physical dependence on opioids or who have opioid use
disorder. 105
Gap 20: Lack of information about treatment options in the Catskills. 106
Gap 21: Few pain management resources. 107
Gap 22: There is a lack of harm reduction resources in the Catskills. 107
Gap 23: Data about substance use, drug markets and overdose is difficult to get. 108
Gap 24: No coordinated way to screen for and respond to drug use in local
emergency rooms. 109
Gap 25: Risk of overdose is especially high when a person is discharged from
treatment or jail. 110
5
Executive Summary
To reduce morbidity and mortality from the overdose crisis in the Catskills, the Catskills
Addiction Coalition (CAC) plans to prevent addictions, improved treatment and recovery
services, identify gaps and develop strategies for prevention, treatment and recovery in the
coming one to three years.
This Needs Assessment and Gap Analysis, funded by a Rural Communities Opioid Response
Program Planning Grant from the federal Health Resources and Services Administration,
surveys opportunities and gaps in opioid use disorder prevention, treatment, and recovery
workforce, services, and access to care within the Catskills region.
Values
We value transparency, connection, collaboration, warmth, relationships, healing, data-informed

strategies, consensus-based decision making, equitable distribution of resources, stakeholder
concurrence, and non-judgmental listening in this process
Target Populations
The Catskills Addiction Coalition is focusing on the following target populations:
● disconnected youth
● all area youth
● pregnant people with opioid use disorder or who have physical opioid dependence, and
newborns discharged from the hospital with neonatal withdrawal syndrome
● people who use drugs and other substances
● people who consider themselves in recovery
● the families and friends of people who use drugs or who are in recovery
● the general population
Key Findings
● Opioid overdose death rates in the Catskills were extremely high by both state and
national standards in 2016, and were among the highest in the New York State in 2018.
6
Rate of fatal overdose deaths per 100,000 population1
2016 2018
Delaware County 26.7 24.2
Greene County 30.4 25.3
Sullivan County 24.1 41.4
Ulster County 33.6 31.2
New York State average 15.1 14.9
National average 19.8 no data
● Evidence-based treatment strategies such as medication assisted treatment with

buprenorphine and targeted naloxone distribution are promising harm reduction
strategies that have some success in the region that can serve as a foundation for a
harm reduction approach to the overdose epidemic in the Catskills.
● The rate of disconnected youth in the Catskills region in 2017 was higher than the
national average of 11.5%.
● Treatment and recovery of youths under the age of 18 who have substance use
disorders is largely unaddressed in the Catskills region, yet several of the people in
recovery we have spoken with began using substances in high school or younger.
● Local youth report using alcohol more than any other substance, including opioids.
● Hospital discharge data and anecdotal evidence gathered from interviews with key
informants suggests that the Catskills region has a large population of people who are
using opioids while pregnant, and that they and their infants aren’t receiving optimal
medical care.
● The Catskills’ community’s cultural approach to and perceptions of addiction and
recovery cause a tremendous amount of resistance to creating, adopting and sustaining
programs that can help people people who use drugs and people in recovery. Cultural
and institutional resistance to a harm reduction approach to reducing morbidity and
mortality from substance use is rampant, subtle and powerful.
Priority Needs and Issues

We have gathered data using a variety of methodologies (see Appendix A and B) to create a list
of needs and gaps, which are paired with corresponding opportunities and assets. We then
ranked these needs and gaps their priority to the members of our consortium (see Appendix F).
According to our consortium, the top ten priority needs related to opioid use and the overdose
crisis are:
1
Data from the New York State 2018 Opioid Report,
https://www.health.ny.gov/statistics/opioid/data/pdf/nys_opioid_annual_report_2018.pdf, the New York
State - County Opioid Quarterly Report, October, 2019,
https://www.health.ny.gov/statistics/opioid/data/pdf/nys_oct19.pdf, and “Drug Overdose Deaths,” Centers
for Disease Control and Prevention, https://www.cdc.gov/drugoverdose/data/statedeaths.html.
7
1. Lack of communication and collaboration among stakeholders, service providers and
community members -- Priority score: 59
2. No affordable public transportation in much of the region -- Priority rank 57
3. Lack of focus on substance issues and youth, particularly “disconnected youth” -- Priority
score: 56
4. Low number of qualified workers in Catskills region; high number of people in recovery
who need work -- Priority score: 49
5. The community needs a resource to go for drug use referrals, ideally with the word
“opioid” or “drug use” in the title -- Priority score: 44
6. Stigma causes resistance to adopting harm reduction programming -- Priority score: 43
7. Certified recovery peer advocates (CRPAs) are not available easily and accessibly
throughout the region -- Priority score: 42
8. Local mental health care services don’t necessarily address substance use -- Priority
score: 40
9. No transitional affordable housing with adjacent accessible transportation available for
people in early recovery -- Priority score: 38
10. Cultural divides and a lack of understanding of conditions on the ground has tied up
$150,000 in opioid funding -- Priority score: 37
Once we have chosen our priority needs, we group the needs and related opportunities into
related issues, each of which is assigned several “champions” and facilitators. These leaders
take responsibility for tackling each issue, becoming the co-chairs of committees and small
groups that are assigned to each issue that tackle specific, achievable projects.
Below are the priority issues and related projects currently being planned by our consortium:
1. Coordination and communication: Media, outreach, connection

2. Transportation: Lobbying for a public transportation system in Delaware County
3. Youth Engagement: Youth center, certified recovery peer advocates
4. Recovery-Friendly Businesses: certified recovery peer advocates, business outreach
5. Criminal Justice: Law Enforcement Assisted Diversion, substance use help line, re-entry
program
6. Stigma and public education about addiction
7. Mental Health: Margaretville Hospital School Mental Health program
8. Housing: Recovery-friendly housing and transportation
9. Pharmacies: Holistic treatment and recovery services
10. Treatment: Drug use education and screening, MAT induction into local emergency
rooms, increasing access to naloxone, harm reduction, substance use clinics at local
hospitals
8
A. Introduction / Background Information
The rural Catskills region of upstate New York is a place divided by borders. The region is a
patchwork of multiple, counties, school districts, hospital systems, DSRIP (Delivery System
Reform Incentive Payment Program) Medicaid regions, and the catchment areas of several
far-apart major metropolitan areas.
In addition to being divided, the region is also very rural. In the mountainous Catskills region,
bordered by the Hudson Valley to the east, the Southern Tier to the west, and Albany to the
north, you find that population density thins out and the miles between towns begin to rack up.
Delaware County, at the heart of the Catskills, is larger than the state of Rhode Island. Our
geographic catchment area for this grant is Delaware County and portions of Greene, Sullivan
and Ulster Counties that border it. What makes this region singular, aside from its rural
character, is a conservative, sometimes libertarian small-town culture that values self-sufficiency
and loyalty and shares a suspicion of so-called “flatlanders.” If you weren’t born here, you aren’t
from here, so the thinking goes.
This small-town local culture coexists uneasily with a second culture made up of city people and
outsiders who, because of the region’s proximity to New York City, spend part of their time in the
area while also living elsewhere. The Catskills have been a vacationland for “the City” for three
centuries, and the local/“citiot” divide is an old one.
The region’s culture values loyalty and tradition, but also privacy, so much so that while folks
may seem conservative, they are also surprisingly tolerant of deviance and “weirdness.” As Kim
Lacey, the administrative assistant for our project who has lived in the Catskills for more than 40
years, puts it, “As long as you leave me and mine alone, you do whatever you want to do.” This
attitude makes for a community that will observe someone’s substance use for years without
intervening, for fear of not wanting to meddle or cause loss of face. It also allows for
experimentation with innovative and creative solutions to intractable problems: if you want to
open a hemp farm near the center of town, go for it. No one will bother you.
In the Catskills region, the successive waves of the opioid crisis have manifested in a way that
is similar to rural, mountainous regions around the US, particularly those in Appalachia, of which
Delaware County is considered a part. Here, the rate of fatal overdoses are higher than the
state average, and tend to stay higher in comparison while fatal overdose rates around the rest
of the state plateau. (See below for details.)
9
Image source: The Centers for Disease Control.2
During the first wave of the crisis, in the 1990s and 2000s, Catskills healthcare providers
increased the number of opioids they prescribed to their patients in the region. According to the
Drug Enforcement Administration's data about opioid sales collected by the Washington Post,
“from 2006 to 2012 there were 12,402,264 prescription pain pills, enough for 37 pills per person
per year, supplied to Delaware County, N.Y.”
During the same period in Ulster County, 43,367,700 prescription pain pills were distributed,
enough for 33 pills per person per year. In Greene County, 13,828,840 prescription pain pills,
were distributed, enough for 40 pills per person per year. In Sullivan County, 27,245,290
prescription pain pills were distributed, enough for 50 pills per person per year, one of the
highest rates of distribution in the state.3
According to the Centers for Disease Control’s prescribing maps, in 2012 Delaware, Sullivan
and Ulster counties had some of the highest opioid prescribing rates in the state of New York.
2
https://www.cdc.gov/drugoverdose/images/epidemic/3WavesOfTheRiseInOpioidOverdoseDeaths.png
3
Washington Post DEA pills database.
https://www.washingtonpost.com/graphics/2019/investigations/dea-pain-pill-database/
10
The Catskills region has remained a relative prescription hotspot even as overall prescribing
rates have fallen.4
During this period, a local doctor was arrested for distributing massive quantities of prescription
opioids. In 2012, Wayne Longmore, a doctor in Woodstock, was arrested for prescribing large
amounts of prescription opioids to patients. According to a Daily Freeman article from the
period, “Longmore wrote approximately 9,940 hydrocodone prescriptions between Dec. 15,
2010, and Jan. 17, 2012, accounting for nearly 85 percent of all prescriptions he wrote during
that period . . . approximately 4,520 of those hydrocodone prescriptions were for patients under
35.”5
While nationally, the second wave of the crisis began in 2010 with a spike in fatal heroin
overdoses, public awareness of heroin-related arrests and deaths in the Catskills didn’t reach a
fever pitch until 2016, when heroin arrests and fatal overdoses began to spike alarmingly in the
region, and politicians, police and community members were responding with panic and
bewilderment.6
In 2016, all four of the Catskills counties in our region -- Delaware, Greene, Sullivan and Ulster
-- were in the top 25 percent across the state for opioid-related fatal overdoses.7 (Indeed, Ulster
County had the highest rate of fatal overdoses in the whole state that year.) The fatal opioid
overdose rates in Catskills region were much higher than the national average (19.8 per
100,000).8
Beginning in 2013, illicitly manufactured synthetic opioids like fentanyl began causing more fatal
overdoses across the country. By 2016, the last year for which we have data, the rate of fatal
overdose from “synthetic opioids,” the data category that New York State uses to track fentanyl,
was worse in the Catskills than it was across much of New York State in 2016, particularly in
Sullivan, Greene and Ulster counties.9
4
Centers for Disease Control and Prevention, US County Prescribing Rates, 2012
https://www.cdc.gov/drugoverdose/maps/rxcounty2012.html
5
“Dr. Wayne Longmore of Woodstock arrested by federal agents over painkiller prescriptions,” The Daily
Freeman, March 24, 2012.
https://www.dailyfreeman.com/news/dr-wayne-longmore-of-woodstock-arrested-by-federal-agen
ts-over/article_35b2e2ad-3259-5de6-8ee7-8c191ecc0d5a.html
6
“As wave of heroin arrests sweeps Catskills, opioids get political,” Watershed Post, February 23, 2016.
http://www.watershedpost.com/2016/wave-heroin-arrests-sweeps-catskills-opioids-get-political
7
from the New York State 2018 Opioid Report shows
8
“Drug Overdose Deaths,” Centers for Disease Control and Prevention,
https://www.cdc.gov/drugoverdose/data/statedeaths.html
9
New York State Opioid Data Dashboard - County Level,
https://webbi1.health.ny.gov/SASStoredProcess/guest?_program=/EBI/PHIG/apps/opioid_dash
board/op_dashboard&p=gm&ind_id=op52
11
In 2018, New York State’s rate of fatal overdose began to fall for the first time in 10 years,
according to New York State Governor Andrew Cuomo.10
But the rates of fatal overdose remained high in 2018 in the Catskills, outdoing many other New
York State counties. In Delaware County, the overdose death rate was 24.2 per 100,000; in
Ulster it was 31.2; Sullivan it was 41.4 and Greene it was 25.3, according to the New York State
County Opioid Quarterly Report for 2019.11 (In New York, the statewide rate of fatal overdoses
in 2016 was 15.1 per 100,000.12)
Not only were these overdose death rates much higher than the rest of the state of New York,
they were among the highest in the nation.

2016 2018
Across the country, the average fatal overdose rate was 19.8 per 100,000 in 2016 and 21.7 in
2017. For comparison, the highest overdose death rates in the county in 2017 were in West
Virginia (57.8 per 100,000), Ohio (46.3 per 100,000), and Pennsylvania (44.3 per 100,000).14
And Delaware County its own outlying trend: In 2016, the rate of neonatal withdrawal syndrome
-- newborns with neonatal withdrawal syndrome who are affected by parental use of opioids -- in
10
“Deaths Decrease Roughly 16 Percent in New York State outside New York City,” Press release, Gov.
Andrew Cuomo.
https://www.governor.ny.gov/news/governor-cuomo-announces-first-reduction-opioid-overdose-deaths-ne
w-york-state-2009
11
New York State County Opioid Quarterly Report for 2019.
https://www.health.ny.gov/statistics/opioid/data/pdf/nys_oct19.pdf
12
NYS Opioid Annual Data Report in 2018.
https://www.health.ny.gov/statistics/opioid/data/pdf/nys_opioid_annual_report_2018.pdf)
13
Data from the New York State 2018 Opioid Report,
14
Centers for Disease Control and Prevention, Drug Overdose Deaths,
12
Delaware County was the worst in New York State. This indicates that a high number of
pregnant people in the Catskills are using opioids while pregnant, and that both they are their
children need support and understanding in order to thrive. Yet there are no maternity wards in
the Catskills region, and very few maternity services, let alone maternity services that
understand medication assisted treatment.
B. Vision / Mission / Planning Values
Vision: To reduce morbidity and mortality from the overdose crisis in the Catskills.
Mission: Preventing addictions and improving treatment and recovery services, identifying gaps,
and developing strategies for prevention, treatment and recovery in the coming one to three
years.
Planning Values: Transparency, connection, collaboration, warmth, relationships, healing,
data-informed strategies, consensus-based decision making, equitable distribution of resources,
stakeholder concurrence, non-judgmental listening.
C. Needs Assessment Methodologies
Our needs assessment was guided by our commitment to listening and learning in a
non-judgmental fashion to people from every sector in our community. To that end, we focused
on attending as many meetings, conventions and committees as possible, as well as conducting
focus groups, attending sessions of drug court, attending private sessions of doctors
appointments with people in recovery, and conducting over 100 interviews and conversations
with key informants from across the Catskills, many of whom have been rolled into our Catskills
Addiction Coalition as partners and collaborators. For details about the meetings and focus
groups we ran and attended, see Appendix A.
In addition, the Catskills Addiction Coalition organized a community summit in January 2019
that was attended by over 100 people. The day-long summit was designed to inspire members
of the Catskills community to discuss local needs for prevention, treatment and recovery
regarding opioid use disorder (OUD). Together, the group generated a list of existing resources,
a list of sectors to be involved in the Catskills Addiction Coalition, and a list of committees
focusing on the largest perceived gaps.
The CAC will host another summit, which we expect to be attended by 150 people, in January
2020. At this summit, we plan to refine the needs and gaps we identified in 2019 and emerge
with champions, facilitators and action committees assigned to specific action plans for a set of
local projects.
Finally, in order to make sure that the voices of those in recovery are guiding our work and our
priorities, we have designed and workshopped a Living in Recovery Survey that is being
13
distributed by local recovery organizations to their members in exchange for gift cards. Its goal
is to determine gaps and needs perceived by the local recovery community in the Catskills. To
see the survey, see Appendix B.
D. Overview of Results / Findings
a. Populations of focus
Summary of quantitative and qualitative data from the perspective of prevention, treatment and
recovery. Identity the prevalence and severity of needs, as well as impact on and demand for
services. Summarize relevant context and conditions affecting populations of focus.
One of the first challenges of this grant has been to identify which populations of focus our
consortium wishes to serve. In our grant application, we wrote of the need to target
“disconnected youth,” as defined by Measure of America: "teenagers and young adults between
the ages of 16 and 24 who are neither working nor in school.”15
As a result of the research, data gathering, and meeting facilitation we have done since
September 2019, the Catskills Addiction Coalition has widened its scope of focus populations to
include:
● disconnected youth
● all area youth
● pregnant people with opioid use disorder or who have physical opioid dependence, and
newborns discharged from the hospital with neonatal withdrawal syndrome
● people who use drugs and other substances
● people who consider themselves in recovery
● the families and friends of people who use drugs or who are in recovery
● the general population
1. “Disconnected youth”
Quantitative Data: According to the research organization Measure of America, “disconnected
youth” are "teenagers and young adults between the ages of 16 and 24 who are neither working
nor in school.”
Data on the rate of disconnected youths in our region is scant, but a 2019 report from Measure
of America contains county-by-county breakdowns of disconnected youth. This data shows that
the rate of disconnected youth in the Catskills region in 2017 was higher than the national
average of 11.5%.
15
http://measureofamerica.org/disconnected-youth/
14
According to the report, 13.2% of Delaware County’s youths are disconnected; 13.5% in Ulster
County are disconnected; 31.5% in Greene County are disconnected; and 18.2% in Sullivan
County are disconnected. This data is based on Measure of America’s calculations of data from
the US Census Bureau’s annual American Community Survey from 2013–2017.16
Several proxy data sources could help us measure youth disconnection rates in the Catskills:
school dropout rates; GEDs; foster care statistics; arrest reports; club memberships
(four-wheeling, hunting clubs); DSS records; food pantry data; and disability data.
Qualitative Data/Interviews: Many key informants in our community are concerned about
reaching youth, particularly youth that they perceive as not having enough local resources. A
local pastor tells us that he thinks his son died of an opioid overdose because he did not have
access to enough recreational activities to “keep him busy.” A local school psychologist tells us
that she has watched kids develop opioid use disorder once they leave high school.
Prevention, treatment and recovery in the Catskills are not aimed specifically at disconnected
youth. Indeed, while prevention efforts in Delaware County, Ulster County and Greene County
have focused heavily on youth, those efforts are coordinated almost entirely through the public
schools in the region, which by definition excludes the “disconnected youth,” who are not
enrolled in school.
Needs: The lack of focus on disconnected youth in particular is one of the more pernicious gaps
in our region’s efforts to strengthen prevention, treatment and recovery for youth.
Impact on Services: Robbie Martin, of the Margaretville Hospital School Mental Health Program,
which offers mental health counseling services to the families of children in the schools, says
that “the needs of families goes above and beyond mental health needs,” and that the
prevalence of “disconnected youth” is a problem even for her program. She would like to
expand the program to offer more caseworker services for children and their families. She talks
about how the most important need that she sees in her client population is a need for
“connection.”
Scott Burrows, the Delaware County Drug Court Coordinator, said in an interview on December
12, 2019 that the majority of Delaware County drug court participants are young, often in their
twenties, and many of them have had opioid use issues.
Opportunities: Focus prevention, treatment and recovery services on youth, particularly

disconnected youth, in the Catskills, by combining youth engagement projects like a youth
center or a mentoring program with substance use and mental health resources such as
counselors and certified recovery peer advocates. Use the Margaretville Hospital School Mental
16
"Making the Connection: Transportation and Youth Disconnection," 2019.
http://measureofamerica.org/youth-disconnection-2019/
15
Health Program, which offers mental health counseling services to the families of children in the
schools, as a base upon which to expand. Offer in-school offerings to reach community
members who are not in school -- for example, by supporting after-school activities that are
open to all community members and caseworker services for the families of children in the
school. Middle-school aged tweens should be a particular focus on this programming, according
to administrators at Margaretville Central School, who say that that age group is often left out of
activities. New York City has done a considerable amount of policy work on the topic of
disconnected youth, and our consortium can benefit by studying policies and programs that
have worked and may be transferable to a rural region.17
2. All area youth

Quantitative Data: In October 2019, the Margaretville Hospital School Mental Health Program
was treating 219 active patients in four regional school districts, Margaretville, Andes,
Downsville and Roxbury. These patients are students enrolled in the schools, but their families
are often treated as well, coming in for appointments with their children and doing counseling
sessions and appointments with a psychiatric nurse practitioner together.
Robbie Martin, who runs the school mental health program, estimates that maybe 5 out of 80
families that her program sees has some form of substance use issue. The school mental health
program does not have a specific substance use focus, which is an opportunity to explore.
The 2019 Delaware County Prevention Needs Survey Summary shows that alcohol and vaping
are the most popular substances used by youth in the survey population, and that alcohol use is
greater than the national average, but the use of amphetamines, narcotics, sedatives and other
drugs were lower than their national counterparts, according to a nationwide survey called
Monitoring the Future, according to the study’s summary.
In Delaware County, 30.6% of 178 Delaware County students in grades 8, 10, and 12 who were
surveyed had used alcohol in the past 30 days — this is higher than their national counterparts
by 38.8%.18
In Ulster County in 2016 and 2017, 27% of 3,987 students in grades 7 through 12 reported
drinking alcohol within the past 30 days. While less than 1% of those students reported using
heroin at least once in their lifetime, 5% of them reported trying prescription pain relievers at
some point in their life, and 2% reported using prescription opiates in the past 30 days.
According to the survey summary, “Initiation to these drugs begins in later adolescence: 38% of
17
Community Service Society. https://www.cssny.org/advocacy-and-research/entry/youth-policy
18
2019 Prevention Needs Assessment Survey, Delaware County.
https://www.scribd.com/document/438185110/Survey-Summary-2019-Delaware-Co-NY-Assess
ment-docx
16
users were over 14 when they first used prescription opiates, 21% first tried them before the age
of 12.”19
According to the New York State Opioid Annual Report 2018, which aggregates data from the
National Survey on Drug Use and Health (NSDUH), about 7% of youth ages 18 to 25 in New
York State used some kind of non-legal drug other than marijuana in the 30 days leading up to
the survey, which was taken in 2015 and 2016. The data from that report show that such
substance use is highest among that age group. See the illustration below:
Interestingly, according to the same report, the crude rate of buprenorphine prescriptions for
substance use disorder per 1,000 population decreased in New York State for the 18-24 year
old age group, from 29.5 per 1,000 in 2012 to 18.9 per 1,000 in 2017. (The rate of prescriptions
rose for every other age group in the state during the same period.)20
19
Ulster County Youth Survey, 2016-2017.
https://27fab957-0c6d-4b0f-bc4e-582a4c18f3b1.filesusr.com/ugd/2f4fa4_2a56bfb99b9c45a2ade159f6bba
a1cf6.pdf
20
NYS Prescription Monitoring Program; data as of April 2018.
https://www.health.ny.gov/statistics/opioid/data/pdf/nys_opioid_annual_report_2018.pdf
17
Qualitative Data/Interviews: We conducted in-depth interviews with four young people in
recovery, all of whom began using drugs and other substances as teenagers and who said that
additional support for their substance use issues as youths would have helped them recover.
We interviewed school administrators at Roxbury Central School and Margaretville Central
School who spoke of the great need for in-school mental health services. Jeremey Marks, the
Vice Principal of Margaretville Central School, said that the impact on his students would be dire
if the school’s in-school free mental health counselors were to suddenly disappear. Mary
Rosenthal, the director of the Alcohol and Drug Abuse Council of Delaware County, reports that
there is a rash of self-harm among LGBT children at one of our local schools.
Ellen Stewart, a mental health counselor with the Margaretville Hospital School Mental Health
Program, says that when she refers a child to a developmental pediatrician or psychiatrist, there
is usually a six-month waiting period. “For children five and under who need assessments,
counseling and therapy, it’s almost impossible to get an appointment,” she says. “The mental
health clinic, they have to do triage, basically.”
Becky Manning, who runs the local Catskill Recreation Center, has pioneered an innovative
job-training and youth-engagement program that trains local youths to become lifeguards, who
can then be employed at the gym. Friends of Recovery’s new Turning Point Center in Delhi has
a largely young clientele, as does the Narcotics Anonymous group in Delhi, which was founded
by Paul Fontana as youth-friendly alternative to local AA mutual support groups. That NA group
is viewed as highly successful. A local pastor, whose son died of an opioid overdose, said that
he has concluded that local kids need more community engagement such as recreation,
craftsmanship and vocational work.
Prevention: There are quite a few youth prevention programs in the Catskills region. These
resources offer a variety or programming from an array of sources, all of which are targeted
towards kids in a school context. The programming varies from school district to school district
and is highly localized, with little coordination across districts or counties. The programs range
from “Hidden in Plain Sight” workshops geared towards detecting substance use to Teen
Institute, a statewide effort to empower teens, to a Delaware County adverse childhood
experiences project that aims to train teachers in local public schools about trauma-informed
care.
Treatment and recovery of youths under the age of 18 is a taboo topic in the Catskills region. At
no point during months of meetings and conversations in the region has the topic of offering
substance use treatment to youths come up. Yet several of the people in recovery we have
spoken with began using substances in high school or younger. (Our “Living in Recovery”
survey will capture more data about the age of people who first use drugs or other substances.
See Appendix B.)
18
Needs: Prevention services for “disconnected youths” who are not in school, and treatment and
recovery services for youth in the Catskills region.
Impact on services: By ignoring the needs of youths who may require substance use treatment,
our region is neglecting an entire sector of health care. A dearth of youth-oriented mental health
and substance use treatment providers leaves our region’s youth without support. This neglect
is inadvertently fueling the overdose crisis. Paul Fontana, one of our consortium members who
used and sold drugs as a youth in the region and is now recovery, says that he was arrested
eight times but only offered recovery treatment once. Had he been offered treatment sooner, he
says, he would have had a path to recovery sooner.

disconnected youth, in the Catskills, by combining youth engagement projects like a youth
center or a mentoring program with substance use and mental health resources such as
counselors and certified recovery peer advocates.
3. Pregnant people with opioid use disorder or who have physical opioid dependence,
and newborns discharged from the hospital with neonatal withdrawal syndrome
Hospital discharge data and anecdotal evidence gathered from interviews with key informants
suggests that the Catskills region has a large population of people who are using opioids while
pregnant, and that they and their infants aren’t receiving optimal medical care.
Quantitative Data: In 2016, Delaware County had the highest rate of newborns discharged from
the hospital with Neonatal Withdrawal Syndrome (NOWS) in New York State, a rate of 48.1
newborns with NOWS per 1,000 newborn discharges.21 Sullivan County also had a high rate:
28.4 newborns per 1,000 newborn discharges. Ulster and Greene counties had mid-level rates
of 22.9 and 21.3, respectively. (Note that the data uses the term NOWS and not neonatal
abstinence syndrome (NAS), a similar syndrome that is often used interchangeably with
NOWS.)
These statistics suggest that there is a high number of people in the Catskills region who are
using opioids while they are pregnant. But what this NOWS data doesn’t tell us is whether these
pregnant people were using medication assisted treatment such as buprenorphine or
methadone (the gold standard of treatment which should be supported by the community) or
whether they were using illicitly manufactured fentanyl or heroin or diverted prescription and
pharmacotherapy.
21
“Newborns with neonatal withdrawal syndrome and/or affected by maternal use of drugs of addiction,
crude rate per 1,000 newborn discharges (any diagnosis), 2016.” Data from the New York State Opioid
Data Dashboard - County Level, using data from the Statewide Planning and Research Cooperative
System (SPARCS) dataset about hospital discharges.
19
Qualitative Data/Interviews: Anecdotal data from interviews with key informants suggests that
some of these pregnant people are using buprenorphine to manage active opioid use disorders.
Denine Polen, a local nurse practitioner with a buprenorphine waiver, referred a pregnant
patient using buprenorphine to Margaretville Hospital for hospital ultrasound services in the fall
of 2019. The client was repeatedly turned away and eventually went to another healthcare
facility for care, Polen told us in September 2019.
Kurt and Lucinda Grovenberg, addictionologists who rent office space on the Margaretville
Hospital campus, tell us that they have had several local pregnant patients to whom they
prescribe buprenorphine. They also tell us that some of their patients have encountered
ignorance about buprenorphine and NOWS at the hospitals where they have given birth, leading
to the involvement of child protective services in their lives when they are in fact using the best
possible treatment for opioid use disorder that reduces harm for themselves and their infants.
Dr. Dumisa Adams, an obstetrician and gynecologist at the Catskill Regional Medical Group in
Sullivan County, just outside our region, recently gave a talk advocating for the use of
medication assisted treatment in treating opioid use disorder in pregnant women at an opioid
prevention conference in Sullivan County. “She said she had a patient who had been given a
drug that interfered with her MAT, and it sent her into acute tachycardia and put her baby at
risk,” according to a Times Herald-Record article about her talk.22
Needs: More data to track whether pregnant people in the Catskills are using medication
assisted treatment or illicitly manufactured fentanyl or heroin or diverted prescription opioids.
Pregnant people with physical dependence on opioids or who have opioid use disorder need
access to buprenorphine, and maternity and neonatal services that understand and support
medication assisted treatment as the most efficacious way to manage substance use disorders.
Infants with NOWS need targeted services at home in the Catskills once they are discharged
from maternity hospitals outside the region.
Prevention: There is little public discussion about pregnant people with opioid use disorder in
the Catskills, and we found no prevention resources that tackle this specific issue.
Treatment: While there are some MAT providers in the Catskills prescribing buprenorphine to
pregnant people, there are no peer educators who have experience with opioid use disorder
and are also parents who have substance exposed newborns, nor is there much awareness of
how to support pregnant people using buprenorphine or their infants with NOWS at regional
hospitals.
22
Opioid epidemic has deep roots, Times Herald Record, November 3, 2019.
https://www.recordonline.com/news/20191103/opioid-epidemic-has-deep-roots
20
Recovery: There are no resources to support pregnant people using buprenorphine or new
parents with infants with NOWS in the Catskills region once they are discharged from the
hospitals that offer maternity care outside the Catskills and return home.
Impact on Services: The lack of support for pregnant people with opioid use disorder or who
have physical opioid dependence, as well as the total dearth of services for newborns
discharged from the hospital with neonatal withdrawal syndrome, causes confusion and friction
between patients and healthcare providers, increased healthcare costs due to longer hospital
stays for infants,23 and potential prolonged problems for both parents and children.24 According
to health officials in Rhode Island, a state that has made a concerted effort to respond to rising
rates of neonatal abstinence syndrome, a lack of treatment for and understanding of NOWS and
NAS can cause increased costs for the healthcare system.25
Opportunity: Education for medical providers and hospitals about pregnancy and opioid use
disorder could help steer more pregnant people with opioid dependence issues or active opioid
use disorders to medication assisted treatment, reducing their potential use of diverted
prescription and pharmacotherapy or illicitly manufactured fentanyl or heroin. We could reach
out to health officials Sullivan County and in Rhode Island to learn about best practices for
supporting birthing parents who are on medication assisted treatment, neonatal withdrawal
procedures and protocols, the cost savings of recovery programs, the benefits of the child
remaining connected to the mother, and the usefulness of peer educators who are also mothers
who have substance exposed newborns. Margaretville Hospital is introducing several new
OB-GYN providers to the Catskills region, and another, Denine Polen, has set up an
independent practice on her own. These people can be educated about medication assisted
treatment. Perhaps Margaretville Hospital can also introduce some kind of outpatient parent
advisory program to help parents navigate neonatal withdrawal syndrome locally and in
partnership with out-of-county neonatal care units.
4. People who use drugs and other substances in general
Measuring the prevalence of people using drugs and other substances in the Catskills region is
a tricky business, mainly because finding reliable granular data is difficult.
Quantitative data: The three hospital systems in the region do not share the same electronic
medical record (EMR) systems, which makes sharing their data with each other or with public
23
"Dramatic Increases in Maternal Opioid Use and Neonatal Abstinence Syndrome," National Institute on
Drug Abuse.
https://www.drugabuse.gov/related-topics/trends-statistics/infographics/dramatic-increases-in-maternal-op
ioid-use-neonatal-abstinence-syndrome
24
Cognitive and Behavioral Impact on Children Exposed to Opioids During Pregnancy, Pediatrics August
2019, https://pediatrics.aappublications.org/content/144/2/e201905143
25
“Component A of The Rhode Island State Health Improvement Plan,” July 28, 2017.
http://www.eohhs.ri.gov/Portals/0/Uploads/Documents/SIM/HFA04OpioidUseDisorders.pdf
21
health officials difficult. (Source: Delaware County Drug Use Task Force, December 9 meeting,
2019.)
Kim Coppage, the Director of Nursing at Margaretville Hospital, tells us that Margaretville
Hospital averages about two visits to its emergency department per month for mental health
and/or substance use issues.
There seems to be no easy way to obtain data measuring this rate, possibly because of the
EMR system. Coppage said that it is possible to track police incidents in the hospitals’ MIDAS
incident tracking system, but that such an effort would take resources. More work will be
necessary to obtain this data.
Coppage also said that Margaretville Hospital sees one regular patient with opioid use needs
who has been transferred to Kingston, but keeps coming back, and that she would love support
for helping him find a longer-term solution for his needs.
Emily Taggart, the social worker at O’Connor Hospital in Delhi, tells us that she manually looks
through emergency department records to find substance use patients, whom she then refers to
a certified recovery peer advocate from Friends of Recovery who comes to the emergency
department in person.
Opioid overdose death data

Fatal overdoses provide the most concrete information about the crisis in the Catskills. In 2016,
Delaware County had 10 opioid overdose deaths (a rate of 26.7 deaths per 100,000 population),
Greene County had 12 (30.4), Sullivan County had 16 (24.1) and Ulster County had 54 (33.6).26
These death rates are extremely high by both state and national standards:

2016 2018
26
“Data Table 1.2 Overdose deaths involving any opioid, age-adjusted rate per 100,000 population, by
county, New York State, 2016,” New York State Opioid Annual Report 2018, p. 92 through 93.
27
Data from the N
ew York State 2018 Opioid Report,
22
All four of the Catskills counties in our region were in the top 25 percent across the state for
opioid-related overdose deaths per 100,000 population in 2016.28 (Indeed, Ulster County had
the highest rate of fatal overdoses in the whole state in 2016, with a rate of 33.6 deaths per
100,000.) The overdose death rates in all four counties are much higher than the state average
(15.1 per 100,000)29 and the national average (19.8 per 100,000)30 in 2016.
28
New York State 2018 Opioid Report.
29
"Figure 1.1 Overdose deaths, age-adjusted rate per 100,000 population, by substance, New York State,
2010 and 2016," New York State Opioid Annual Report 2018, p. 15.
30
“Drug Overdose Deaths,” Centers for Disease Control and Prevention,
23
In 2018, overdose death rates remained similarly high and, in Sullivan County, spiked
alarmingly, according to data from the New York State County Opioid Report published in
October 2019.31
That year, Delaware County had 11 fatal overdoses at a rate of 24.2 fatal overdoses per
100,000 (up from 10 at a rate of 26.7 per 100,000 in 2016); Greene had 12 at a rate of 25.3
(compared to 12 at a rate of 30.4 in 2016), Sullivan had 31 at a whopping 41.4 rate (up from 16
at a rate of 24.1 in 2016) and Ulster had 56 at a rate of 31.2 (compared to 54 at a rate of 33.6 in
31
New York State - County Opioid Quarterly Report, October, 2019.
https://www.health.ny.gov/statistics/opioid/data/pdf/nys_oct19.pdf
24
2016). All of these overdose death rates were again much higher than the statewide rate of 14.9
fatal overdoses per 100,000 population for 2018.
In January through March of 2019, that the 2018 report shows that Delaware County had one
fatal overdose, Greene County had four, Sullivan County had five and Ulster County had seven.
The role of fentanyl in fatal overdoses in the Catskills

It is difficult to tell which substances are driving these drug use trends. New York State’s data on
overdose deaths is lacking when we attempt to track fatal overdoses that are related to illicitly
manufactured fentanyl.
Fentanyl, a powerful synthetic opioid that is much more concentrated than heroin, has driven a
spike in overdose deaths as it flooded the street supply of drugs in the form of an undetectable
additive to heroin, methamphetamine, cocaine and counterfeit pills.32
New York State’s Opioid Annual Report for 2018 attempts to show this trend with the following
graph:33
32
United States Drug Enforcement Administration Fact Sheet on Fentanyl,
https://www.dea.gov/factsheets/fentanyl
33
New York State Opioid Annual Report 2018, p. 28,
25
But this graph also illustrates the limitations of the state’s data. It shows that New York State
lumps its data about fentanyl into a broader category of “synthetic pain relievers.” This makes it
difficult to distinguish fentanyl from diverted and misused prescription opioids, or measure
whether or not New York State drug users have followed national trends of shifting from using
diverted prescription opioids in the 1990s and 2000s to using illegal street drugs like heroin in
the 2010s and then fentanyl beginning in 2014.
The officials who wrote the 2018 New York State Opioid Annual Data Report acknowledge this
problem:
“Because it is not possible to distinguish illicit fentanyl from medically administered

fentanyl in postmortem toxicology testing, all fentanyl-related deaths are classified in
the same way – labeled as ‘synthetic opioids, excluding methadone,’” they write. “In
NYS, increases in deaths involving synthetic opioids, excluding methadone, drove
most of the increase in the age-adjusted rate of deaths involving any opioid pain
26
reliever, an overwhelming majority of which involved fentanyl. It is also important to
note that overdose deaths increasingly involved both heroin and synthetic opioids,
excluding methadone, together. A similar pattern was also observed for deaths
involving both cocaine and synthetic opioids, excluding methadone, together. These
combinations typically include fentanyl.”34
Even with this significant problem, New York State’s data suggests that fentanyl is driving a
sharp rise in fatal overdoses beginning in 2015.
In the state’s 2018 opioid report, two maps show the Catskills region topping the state both for
overdose deaths related to heroin and to “synthetic opioids other than methadone,” the category
that includes fentanyl. They also show that the Catskills seems to have more overdose deaths
caused by “synthetic opioids” than by heroin. Because New York State says that its “synthetic
opioids” category is largely tracking illicitly-produced fentanyl, these graphs imply that the region
is reflecting the larger nationwide third wave of the overdose crisis, where illegal fentanyl is
contributing to to a sharply-rising rate of fatal overdoses.
34
New York State Opioid Annual Report 2018, p. 15 and 16.
27
28
Other drug use data
Delaware County Drug Court Coordinator Scott Burrows says that drug court has had only two
graduates in 2019. The court has 14 participants right now, as of December 12, 2019. It had 13
graduates in 2018. Lately, however, Scott says that alcohol has been more of a problem in the
drug court population, and that there has been a worrying uptick in methamphetamine.
29
While a decrease in the use of opioids may seem reassuring, the increase in the prevalence of
fentanyl in the regional drug supply increases the likelihood of fatal overdose, particularly for
people who are not used to using opioids and who have little tolerance for the substance. Also,
the use of alcohol and methamphetamines, especially when used together or with other
substances like opioids, can increase the risk of fatal overdose.
In 2018, there were 99 Delaware County residents who were admitted to OASAS-certified
chemical dependence treatment programs for heroin use, and 152 residents admitted for any
opioid use, including heroin. (Where these people went, and whether they attended Delaware
County’s sole in-county clinic, isn’t tracked.35)
In Delaware County in 2018, EMS administered naloxone 17 times; the police administered
naloxone three times, and a registered COOP program administered the drug 10 times. Source:
New York State Office of Alcoholism and Substance Abuse Services (OASAS).) These rates of
naloxone administration are quite low when compared with Greene, Ulster and Sullivan
counties.36
One proxy set of data for measuring the prevalence of substance use is data about the rates of
certain kinds of infectious diseases associated with intravenous drug use: Hepatitis C, HIV, and
opportunistic infections like endocarditis and osteomyelitis and complex abscesses.
In Delaware County in 2018, there was only one new diagnosis of Acute Hepatitis C in 2018.37
Because new cases of Hepatitis C are usually asymptomatic, because there are few harm
reduction programs in Delaware County, and because the high level of local stigma makes it
unlikely that a person would tell their local healthcare provider about their drug use, it is likely
that this low number does not indicate a similarly low rate of intravenous drug use in the region.
In 2016 in Delaware County, the most recent year for data from the New York State Department
of Health, there were two new HIV diagnoses.38 Whether these HIV diagnoses were related to
intravenous drug use is difficult to determine, for the same reasons outlined above. But
Delaware County, like all the counties in New York State, were identified as being as
“experiencing or at risk of outbreaks” due to injection drug use by the Centers for Disease
Control.39
35
New York State Office of Alcoholism and Substance Abuse Services (OASAS)
36
New York State Opioid Annual Report 2018,
37
“Communicable disease in New York State Cases Reported in 2018,”
https://www.health.ny.gov/statistics/diseases/communicable/2018/docs/cases.pdf
38
Delaware County Public Health Services Annual Report 2017
http://delawarecountypublichealth.com/delaware-county-public-health-services-annual-report/ph
-20170000-annualrpt/
39
“Vulnerable Counties and Jurisdictions Experiencing or At-Risk of Outbreaks,” Centers for Disease
Control, https://www.cdc.gov/pwid/vulnerable-counties-data.html.
30
Our attempts to find data on opportunistic infections that correlate with drug use have come up
empty, but we have talked with Judy Williams, the infection care nurse at Margaretville Hospital,
who says that she will share that data with us in the future. She says that she is not seeing
opportunistic drug-related infections at Margaretville Hospital, but that doesn’t necessarily
mean that there aren’t any in the community. “They don’t usually come here for that,” she says,
suggesting that fear of being seen with a drug-related infection might would keep people from
using the small local hospital where they might recognize their neighbors for drug-related needs
like this.
Waivered providers of MAT are listed in a federal SAMHSA database40 that doesn’t sort them by
county but rather by postal code and city, making it difficult to accurately assess how many
waivered providers are actually providing services in the Catskills region. Compounding this
problem is the fact that some local providers who are waivered do not appear in the database,
while others who are are listed in counties where they are registered but not necessarily where
they are providing services. (For more information on this, see the “Medication Assisted
Treatment” section below.)
We have attempted to gather basic data about buprenorphine providers by contacting local
providers individually and asking them for 1) the number of patients they are allowed to see and
2) the number of patients they actually see who are from the Catskills region. Despite our
efforts, we have received this data from none of them at the time of filing this report. More
resources and a deeper dive will be needed to accurately track providers and assess their
capacity and number of patients served.
The Catskills region does have high rates of clients admitted to OASAS-certified chemical
dependence treatment programs for any opioid. The map below compares crude rates of
admittance per 100,000 population, by county, in 2017. Counties that had the highest crude
rates in 2017 are shaded in blue. In 2017, the top 16 counties in the highest quartile included
Sullivan and Greene counties.
40
SAMHSA Buprenorphine Practitioner Locator
https://www.samhsa.gov/medication-assisted-treatment/practitioner-program-data/treatment-practitioner-l
ocator?field_bup_physician_us_state_value=NY
31
Qualitative Data: We have not yet talked with people who are actively using drugs and who do
not consider themselves in recovery. This illustrates a gap in our methodology, that we hope to
fill by gathering more data from our network, including family members and certified recovery
peer advocates, about how to best locate people who use drugs and are not part of the recovery
community.
Needs: The Catskills region is large and there appears to be variation throughout the region in
which drugs are used where and what kinds of drugs cause overdose deaths. For example, our
informants in Delaware County tell us anecdotally that opioid use is falling and meth use is
rising in Delaware County, while fentanyl overdose deaths have become more widespread in
Ulster County in 2019.
This is an opportunity to talk to key interviews with people who use drugs and those who serve
them in regional markets to gain a better sense of how the landscape operates. Our response to
substance use in the region can be tailored to different conditions in different parts of the
Catskills.
One promising method of reaching people who use drugs and are not yet in recovery is to
establish a county help line. Drug use hotlines and help lines already exist in Ulster and Sullivan
32
counties, and our office has begun receiving calls from people who would use such a resource.
Since September 2019, our office has received five such calls, including a referral from a local
provider, a woman who had been discharged from Schoharie County and needed help; a call
from hospital employee who had a friend with a child with a substance use disorder; a call from
the stepmother of that same person, and a call from a woman who was leaving inpatient drug
rehab and who needed a referral.
4. People who consider themselves in recovery from substance use

We know anecdotally that there is a large and robust recovery community in the Catskills region,
but there is a lack of data quantifying how many people in the region think of themselves as “in
recovery” from substance use.
Quantitative Data: The best data about people in recovery in New York State is the 2017 “Life in
Recovery” Survey from NYS Friends of Recovery.41 It collected responses from 431 people who
identified as being in recovery across New York State.
We will attempt to localize this data in our forthcoming “Living in Recovery” survey for the
Catskills region, which asks respondents to report whether they consider themselves in
recovery. Data from this survey, which will be available in February 2020, will be added to this
Needs Assessment as an addendum.
Qualitative Data: We conducted in-depth interviews with four young people in recovery, who told
us that there are a large number of people in recovery in the Catskills region. We also observed
an afternoon of buprenorphine treatment sessions with Kurt and Lucinda Grovernberg,
addictionologists who have offices on the Margaretville Hospital campus, on October 31, 2019.
The Grovenbergs also asked their
“We have a strong recovery community,” says Paul Fontana, the founder of Delhi’s Narcotics
Anonymous group. There are many Alcoholics Anonymous groups that meet in the Catskills
region, and four Narcotics Anonymous groups meet in the region.42
We have had multiple meetings with the heads of the two main recovery organizations in the
region: Friends of Recovery Delaware Otsego in Delhi and Samadhi Recovery Community
Outreach Center in Kingston. Both recovery centers tell us that they have a large demand for
their services, although they have not shared specific data with us about how many people they
serve currently. Samadhi aims to serve 1,200 people per year, according to its website.43
41
“Recovery in the Empire State 2018 Report on Findings,”
https://for-ny.org/wp-content/uploads/2019/08/Life-in-Recovery-Report-FINAL.pdf
42
ADAC of Delaware County.
43
“Early projections are to serve a minimum of 1200 people per year.” https://samadhiny.org/model
33
Needs: Recovery services and resources in the Catskills needs more coordination,
collaboration, communication and outreach to reach their target populations of people who use
drugs and people who are in recovery. Building connections and partnerships with community
organizations like gyms, churches and businesses will help expand this reach. Mutual aid
groups led by people in recovery also require support support for specific needs, such as
re-entry into community life from incarceration.
Opportunities: A recovery re-entry group led by Paul Fontana in Delhi aims to offer regular
mutual aid meetings, subsidized gym passes, employment referrals, group exercise
opportunities, and trainings on re-entering life from incarceration to people in recovery.
5. General population
Quantitative Data: Drug use is considered the “greatest health-related concern” facing Delaware
County, according to the 2019 Delaware County Community Health Assessment, which
surveyed residents of the county about their “greatest health-related concerns:”44
44
Delaware County Community Health Assessment, Presented to: Delaware County Long Term Care
Council, July 31, 2019. Rural Health Network of South Central New York.
34
In the summer of 2019, the Catskills Addiction Coalition and the Central Catskills Chamber of
Commerce co-hosted a Recovery Friendly Businesses breakfast that recruited local business
owners to employ people in recovery. The chamber and the CAC have since gotten interest
from several local businesses, and we plan to partner with Friends of Recovery Delaware
Otsego, who will run the program by supporting employees and employers with peers. We can
also collaborate with the Mountaintop Cares Coalition, which is working with county labor
officials on a similar program.
Qualitative Data: As we have conducted our research through conversations, interviews,

meetings and focus groups, it has become clear that the Catskills’ community’s cultural
approach to and perceptions of addiction and recovery shape the ways that the focus
populations are treated and the ways in which programs can take root to help them.
While we have been using the shorthand of “stigma” to describe the cultural and institutional
resistance to a harm reduction approach to reducing morbidity and mortality from substance
use, that term is inaccurate and fails to take into account the subtle and deep cultural values
and dynamics that are at play.
Cynthia Heaney, the Delaware County Director of Community and Mental Hygiene, says that
stigma (her word) about substance use and mental health has been a pervasive and
confounding problem for her work.
“When I first came on board, I said, ‘We’ve got to do something with stigma reduction.’ Oh my
goodness, the viciousness that has come out on Facebook, as well as comments in the
community about the population that we serve. Things like, “Oh my god, not those people, we
don’t want those people in Walton.” Or “Why don’t those drug addicts just say in Hamden.” Or
“our communities will no longer be safe” or “I won’t let my children outside anymore.”
Opportunities: Cultural education/stigma are a huge opportunity in the Catskills. There are
homegrown education and outreach projects about addiction and mental health in the Catskills
community already, based on the work of Jessica Vecchione, a local filmmaker who made a
documentary about opioid use in Delaware County, who takes this show to communities along
with panels of people who have been affected by addiction and recovery. Jessica’s work was
recognized by Cynthia Heaney, who runs the Delaware County mental health and substance
use departments, and Heaney applied for a SAMHSA grant to hire Vecchione to produce a
series of videos to combat stigma. This work has been approved by the Delaware County Board
of Supervisors, the county’s governing body, which is a tremendous amount of buy-in in a
conservative rural county. Such work could be transformative for our region.
There is a hunger for information about drug and substance use, addiction and recovery among
the general population in the Catskills.
35
At a screening of “Smacked!”, a documentary about opioid addiction, Mountaintop Cares
Coalition on Nov. 11 in the Greene County town of Windham, an audience of over 100 people
all raised their hands when asked if they had been impacted by addiction.
There has been good attendance at all other CAC meetings, including the CAC first meeting, a
naloxone training, the CAC 2019 Summit, showing that the general public has a high level of
engagement in this topic.
b. Findings for service systems

Summary of existing efforts for prevention, treatment and recovery; availability and access to
care; assets and opportunities; and gaps and constraints. Estimate prevalence of and demand
for OUD services. Identify existing and possible federal, state and local resources that can be
leveraged.
1. Prevention
Primary prevention
The Central Region Prevention Resource Council and the Alcohol and Drug Abuse Council of
Delaware County in Delaware County; the Ulster Prevention Council
(https://www.ulsterpreventioncouncil.org/) and Family of Woodstock in Ulster County; and Twin
County Recovery Services in Greene County anchor the primary prevention efforts in the
schools in both counties. Some of these programs are funded by local rotary clubs. For
example, the Fleischmanns and Pine Hill Rotary fund Margaretville Central School’s Teen
Institute Program. Others, like Delaware Opportunities’ Big Brother Program, are run by local
nonprofits.
Catskills Recreation Center has partnered with the Margaretville Hospital Wellness Committee
on a prevention and workforce development program geared towards training young people to
become lifeguards in the region.
Several of our informants in the healthcare industry cited a lack of proper pain management
care as a driver of opioid use in our region. The manager of a local clinic said that one of her top
needs is access to “referral plans for pain management” for her patients. This is an opportunity
to find and connect people with pain issues to pain management programs, thereby reducing
their risk of turning to diverted prescription opioids or street drugs to control their pain. Look at
Ellenville Regional Medical Center for an example of collaborate pain management practices,
and perhaps bring representatives from Ellenville to Margaretville Hospital.
Reaching communities that are difficult to reach is one of our largest prevention concerns.
People who are difficult to find -- such as disconnected youth -- require creative strategies to
reach them where they are. And barriers between consortium members compound the problem.
Most members of our consortium have cited barriers to communication and collaboration as
36
their number one concern when it comes to responding to the overdose crisis. There is no
centralized place for events and information about addiction in the Catskills region. This was the
most-mentioned concern aired at the consortium’s kickoff meeting on Oct. 30, 2019.
Misinformation, conflicting information from different sources, and a general lack of trustworthy
information make the rest of the work of our consortium difficult.
A lack of public transportation is cited over and over again by everyone we speak with.
Delaware County is one of only two counties in New York State without public transportation.
From a prevention perspective, people have less access to healthcare, recreation, and work.
Overdose Prevention: Police response and naloxone distribution and training

In the Catskills, the police are the main point of contact between the government and people
who use drugs or who are in need of medical services because of overdose. There is a great
deal of fear among police for dealing with “dangerous” situations when responding to drug use
calls. At our focus group with Catskills sheriff and state police representatives, multiple officers
spoke of the need for more safety resources for police when encountering people who use
drugs. There was also a negative perception of medication assisted treatment: the head of
Delaware County’s probation office, an investigator with the New York State Police, the head of
the county’s homeless shelter and the Delaware County Sheriff all expressed skepticism about
the efficacy of buprenorphine for managing substance use disorder, saying that they had heard
anecdotally that buprenorphine didn’t work.
This fear and lack of understanding can create tension in emergency situations involving
substance use. Nelson Delameter, the Margaretville Fire Department Chief, says that often the
New York State Troopers on a scene will aggravate overdose survivors and make the situation
more volatile.
The police’s role as the first point of contact can also interfere with getting people connected to
health resources. In the fall of 2019, there was an incident at Margaretville Hospital where an
agitated person who was suspected to have some kind of substance use issue did not make it
into the hospital. Instead, the police arrived and took this person to a destination outside the
region. I have heard multiple reports about this incident from folks in the hospital but have been
unable to substantiate it with data, despite investigating with the Quality Assurance department,
Security and the Head of Nursing.
Beginning in January 2020, a new bail reform law in New York will change the way the police
arrest and hold people. People who are encountered by the police in New York State will no
longer be held on bail for most offenses, including substance use offenses. Craig Dumond, the
Delaware County Sheriff, says that this means that services for people who use drugs will
suffer. “We will no longer have a captive audience,” he says. “They want us to do everything.
We are the default mental health agency.”
37
This is an opportunity to work with local police, hospitals, and social services providers to build a
referral service for police to direct people with substance use issues toward help. As the police
find themselves needing a new way to handle people who use drugs at the point of arrest, offer
them ways to refer those people to social services, following Law Enforcement Assisted
Diversion guidelines. Regional police agencies are interested in this approach, and some, like
Schoharie County and Ulster County, area already implementing them. Police and providers in
Sullivan County, Delaware County and Greene County are curious about this approach. This is
an opportunity to bring them together to learn from each other.
Most local police do not carry or administer naloxone. Naloxone training and distribution is
scarce in the Catskills region. There have been several naloxone trainings in the past several
years in the region, at the Margaretville Telephone Company, the Arkville Fire Department, and
several trainings at two libraries run by the Delaware County Drug Use Task Force in 2019.
Friends of Recovery Delaware Otsego also hosts regular naloxone trainings.
In Delaware County in 2018, EMS administered naloxone 17 times; the police administered
naloxone three times, and a registered Community Opioid Overdose Program administered the
drug 10 times. In 2017, EMS administered naloxone 22 times.45 In 2016, EMS administered
naloxone 28 times. For comparison, in 2016 EMS administered naloxone 147 times in Ulster
County and 60 times in Greene County. (EMS administered naloxone only 14 times in Sullivan
County in 2016, however.)46
These rates of naloxone administration in the central Catskills region are quite low when
compared with Greene and Ulster counties, and with the rest of the state.
Naloxone trainings have drawn interest from a range of participants in the Margaretville region,
and with coordination and organization could be spread throughout the region. Eight people
from a variety of local organizations attended a naloxone Training at Margaretville Hospital
December 3, 2019, and several have followed up to indicate that they would like trainings for
their own organizations. At the training, the OASAS trainer said that hospitals and individuals
can become Opioid Prevention Programs and can sign up to distribute naloxone for free.
According to the OASAS trainer, the only OPP signed up in Delaware County is the Village of
Delhi Police Department. This is an opportunity to distribute free naloxone in the region, and to
coordinate existing efforts, like FOR-DO and others. Kim Lacey, the administrative assistant on
our grant, has begun her training to become a naloxone trainer with local rural cultural
understanding.
45
New York State - Opioid Annual Report, 2018,
https://www.health.ny.gov/statistics/opioid/data/pdf/nys_opioid_annual_report_2018.pdf, p. 105
46
New York State - Opioid Annual Report, 2017
https://health.ny.gov/statistics/opioid/data/pdf/nys_opioid_annual_report_2017.pdf
38
According to the New York State OASAS trainer who conducted our naloxone training, risk of
overdose is especially high when a person is discharged from treatment or jail. She suggested
that issuing a naloxone kit to everyone leaving rehab or jail would prevent overdose, because
people are at particularly high risk of overdosing when they return home from such institutions.
This is an opportunity to create a targeted campaign to distribute naloxone to people leaving
jails and rehab and returning to the Catskills region, and to their families. There may be may be
DSRIP Medicaid funding for “transitional care” that could fund this program.
Harm reduction: Prescription take-back boxes and community sharps collection boxes
Above: Harm reduction resources are sparse in the darker green shaded portion of the map,
which indicates the Catskills region. From the Point, a New York State-specific locator tool for
harm reduction material and services (e.g. sterile syringes, disposal sites of used syringes and
drugs, naloxone, and free HCV testing). w ww.thepointny.org.
There is a general lack of resources that aim to reduce the harm of using drugs in the Catskills
region. According to the New York State Department of Health Opioid Overdose Prevention
Initiative47 and The Point, its accompanying map website,48 there are zero drug dropoff sites in
the Catskills. This isn’t accurate, but the real number is still low. We know of two prescription
take-back programs in Delaware County, at the Margaretville Hospital Community Pharmacy
47
https://www.nyoverdose.org/
48
http://www.thepointny.org/,
39
and the Delaware County Sheriff’s Office. The Delaware County Sheriff’s Office drug take-back
box is underpublicized, and the Margaretville Hospital Pharmacy take-back box is only available
during business hours.
There are four community sharps collection sites in the region, at Margaretville Hospital in
Margaretville, O’Connor Hospital in Delhi, UHS Delaware Valley Hospital in Walton, and
Tri-Town Regional Hospital in Sidney. There is only one HIV/Hep C testing center in the region,
at the Family Planning of South Central NY in Walton. There are no syringe exchanges and only
one Opioid Prevention Programs (OPP), the Village of Delhi Police Department, that is signed
up to distribute naloxone for free.
2. Treatment
Medication Assisted Treatment in the Catskills

There are no emergency departments that offer buprenorphine induction in the Catskills region.
Ellenville Regional Medical Center in Ulster County, an hour-and-a-half away from Margaretville,
is the only nearby rural critical access hospital that will start patients on a three-day
buprenorphine prescription with the support of Certified Recovery Peer Advocates from Catholic
Charities of Orange, Sullivan and Ulster Counties. This program, called Project RESCUE, began
in 2019, according to the Times Herald-Record.49
There are no OASAS-certified clinics offering a full range of medication assisted treatment in the
Catskills region. The Delaware County Alcohol and Drug Abuse clinic in Hamden, which has
satellite clinics on the Margaretville Hospital campus, in Sidney and on the SUNY Delhi campus,
does offer naltrexone (Vivitrol), but no buprenorphine or methadone. The other nearest
substance use disorder clinics are in Binghamton in Broome County, Kingston in Ulster County,
or Albany in Albany County — all more than an hour’s drive away from the region.
There is unused capacity and empty beds at Margaretville Hospital, and several consortium
members, including administrators at the hospital, are interested in establishing a local
substance use clinic could fill that empty space.
There were two buprenorphine trainings for medical providers in Delaware County in 2019
sponsored by the Delaware County Drug Use Task Force, but these trainings had a very hard
time recruiting local medical providers and did not result in any newly waivered providers in the
county, according to Kali Delmar, the coordinator for the task force.
According to the SAMHSA Medication Assisted Treatment Provider Database, there are only
eight providers with waivers to prescribe buprenorphine in the rural Catskills region.
49
“Ellenville hospital at forefront of new approach to treating deadly substance abuse,” Times
Herald-Record, November 16, 2019.
https://www.recordonline.com/news/20191116/ellenville-hospital-at-forefront-of-new-approach-to-treating-
deadly-substance-abuse
40
Providers with waivers to prescribe buprenorphine in the Catskills
Julia Schultz NP UHS Sidney Primary Care44 Pearl Street Sidney Delaware
Anita Akhtar MD 460 Andes Road Delhi Delaware
Denine Polen NP 460 Andes Road Delhi Delaware
Kelly Cable-Stone NP 1 Hospital Road Walton Delaware
Delaware Valley Hospital, Family Health
Vadim Davydov M.D. Center2 Titus Place Walton Delaware
Eric Dohner 6 Franklin Road Walton Delaware
United Health Services Primary Care
Jean Gaetano Roscoe1 titus place PO Box 333 Walton Delaware
HQMP-MAVERICK PRIMARY CARE404
Maya Hambright M.D. ZENA ROAD Woodstock Ulster
Source: https://www.samhsa.gov/medication-assisted-treatment
It is notable that while there are waivered buprenorphine physicians in Greene, Sullivan and
Ulster counties, they are all located in the metropolitan centers instead of in the more rural parts
of those counties, and therefore are not listed here.
The information in the SAMHSA buprenorphine provider database is erroneous, however: We

know anecdotally that there are several local physicians with suboxone waivers in the region.
Khurram Farooq at Margaretville Hospital has his buprenorphine waiver but has not yet
prescribed any to any patients. Kurt and Lucinda Governberg, who are addiction specialists who
have a main office based in Kerhonkson, in Ulster County, operate a satellite office out of an
office building on the Margaretville Hospital campus, where they see a roster of patients from
Delaware County and beyond. (The Grovenbergs do not accept Medicaid, while some other
providers do.)
There are no doubt more buprenorphine waivered providers who are not appearing in the
database.
We have attempted to gather data about the capacity of Catskills buprenorphine providers and
the relative amount of patients they are actually seeing by contacting local providers individually
and asking them for 1) the number of patients they are allowed to see and 2) the number of
patients they treat who are from the Catskills region. Despite our efforts, we have received this
data from none of them at the time of filing this report. More resources and a deeper dive will be
needed to accurately track providers and assess their capacity and number of patients served.
Anecdotally, however, we are told that the Grovenbergs in Margaretville and Vadim Davydov in
Walton do not see anywhere near their capacity of buprenorphine patients.
41
Interestingly, the perception of the number of outpatient providers who are waivered to prescribe
buprenorphine is wildly different from the reality even in one of the large metropolitan areas at
the border of the Catskills region. Margaretville Hospital’s parent organization, WMCHealth
Network, runs the anchor HealthAlliance Hospital in the city of Kingston in Ulster County, and
also runs the OASAS-certified outpatient treatment program and clinic at the Bridge Back
Outpatient Addiction Treatment Program in Kingston. During a meeting with clinic staff on
October 14, 2019, several local clinicians stated that there were “no outpatient providers to refer
to” once patients were discharged from the Bridge Back clinic, despite the fact that there are 36
waivered providers listed in Ulster County, most of them in the Hudson Valley relatively close to
Kingston.
Counseling, Care Coordination and Certified Recovery Peer Advocates (CRPAs)

It is difficult to assess how many Catskills MAT providers offer therapy or access to counseling
as part of their services, but anecdotal evidence suggests that some of them do not. (Denine
Polen called our office asking for referrals for her patients who use buprenorphine to
counseling.) More resources and time will be required to access this information properly.
The Pine Hill Community Center, located in Ulster County near the border with Delaware
County, offers addiction counseling services through Catholic Charities one day per week.
Alcohol and Drug Abuse Services of Delaware County provides consultations, drug and alcohol
assessment in cooperation with the local court and probation systems, and individual and family
treatment for substance use issues.
Rehabilitation Support Services, Inc. (RSS) provides community-based mental health and
substance abuse services in Delaware, Ulster and Sullivan counties. RSS offers rehabilitation
services aimed at addressing the needs of persons with co-conditions of both mental illness and
substance abuse. According to Jayne Francisco, the program director of Delaware County’s
RSS, her program employs a peer that specializes in both mental health and substance use and
care coordination and in-home stabilization for people in crisis.
Other mental health care in the region doesn’t necessarily cover substance use. The
Margaretville Hospital School Mental Health program doesn’t explicitly offer substance use
treatment services to the hundreds of students and their families who receive free counseling.
The school mental health program is popular and is receiving requests from other school
districts to expand, but its staff are too busy to grow the program without outside help. With
funding for more counselors who can focus on substance use in children and families, this
program could be expanded to include such treatment. Rehabilitation Support Services, Inc. has
a shared mental health/substance use peer. Perhaps such a peer could work in the school
system. We can leverage mental health and substance use resources to complement each
other and collaborate.
42
Friends of Recovery Delaware-Otsego Counties operates a walk-in center in Delhi called the
Turning Point, where people in recovery and their friends and families can come consult
certified recovery peer advocates for free. Samadhi Recovery Community Outreach Center in
Kingston operates a walk-in center and a 24-hour call line that connects people in need to
certified recovery peer advocates.
Certified recovery peer advocates (CRPAs) are not available easily and accessibly throughout
the region, but are only available at the Delhi Turning Point Center during business hours.
Samadhi is experimenting with a 24-hour on-call peer delivery model, and Friends of Recovery
is hoping to staff peers at Margaretville Hospital, but bureaucratic barriers to these partnerships
such as review by legal departments and funding must be overcome first. It is particularly
notable that the Delaware County Drug Court lacks a recovery-based model of care, isn’t
integrated into the healthcare system, and doesn’t collaborate with FOR-DO, the local recovery
organization, to have a peer support its participants. This is an opportunity to explore flexible
funding and collaboration models with peer agencies. We would like to work with Samadhi and
FOR-DO to staff peers in accessible locations or have them respond in an “on-call” manner
when needs arise, in partnership with local emergency departments, hospitals, private
businesses, police departments and drug treatment courts.
There is no coordinated way to screen for and respond to drug use in local emergency rooms.
At Margaretville Hospital, staff members tell us that there is no way to screen for substance use
in the current emergency department workflow. This is an opportunity to introduce the SBIRT
substance use screening tool to the emergency department.
Emily Taggart, the social worker at neighboring O’Connor Hospital, tells us that she manually
looks through emergency department records to find substance use patients, whom she then
refers to a certified recovery peer advocate from Friends of Recovery Delaware Otsego who
comes to the emergency department in person.
This is an opportunity to educate emergency department staff about addiction and substance
use and to reframe emergency department missions to include substance use help. Protocols to
include the SBIRT and Brief Negotiated Interview tools, training of staff, convincing of hospital
bureaucracy would be necessary to change the culture of Catskills ED departments to
welcoming places for people with addictions to seek help. We can offer resources and trainings
to introduce those tools to area hospitals.
As hospitals, emergency departments, inpatient rehabilitation organizations, outpatient

medication assisted treatment providers and recovery organizations work to collaborate to
provide continuous, uninterrupted treatment services to people with opioid use disorder, a need
has emerged for the role of “care coordinators” who can bridge gaps between each of these
organizations. Doctor Wesley Ho, who works with providers prescribing outpatient medication
assisted treatment at the Institute for Family Health in Kingston, told us in November 2019 that
there is a great need for this kind of care coordinator role.
43
Maya Hambright, a waivered buprenorphine provider based in Woodstock, and Dr. Gigi Madore,
the medical director of the Kingston Hospital Emergency Department, tell us that people who
visit emergency departments sometimes require bridge prescriptions for buprenorphine, if they
cannot be induced directly in the emergency room directly. Hambright, working with the
Samadhi recovery center in Kingston, is exploring whether to provide those kinds of “bridge”
prescriptions.
As Ulster County works to provide medication assisted treatment in its county jail, it is struggling
to provide the coordination of care that will connect people to their providers when they leave
jail. We have been surprised to observe that no one from the local substance use clinic or the
local hospital system is attending organizational meetings for the jail medication assisted
treatment initiative in Ulster County. This is an opportunity for our consortium to bring local
hospitals to the table and to create care coordination positions that will connect with people as
they leave and return to their lives in the community.
An interesting and innovative approach to treatment is to collaborate with pharmacists, some of

whom hesitant to or stymied from using harm reduction strategies for opioid use disorder. Only
twelve pharmacies in the Catskills region have standing orders to distribute naloxone, according
to the Statewide Directory arranged by County.50 Despite the fact that state law requires that
pharmacies take back unused opioids, the local CVS pharmacy in Margaretville does not
participate. Cindy Cullen, the pharmacist in Margaretville, says that “it’s very dangerous
because it’s like handing cash over to somebody. I can’t take it, I can’t personally put my hands
on it.” The Margaretville Hospital Community Pharmacy isn’t set up for the free naloxone
distribution program because of past institutional resistance.
But local pharmacists are interested in providing holistic prevention, treatment and recovery
care to people with opioid use disorder. A pharmacist in Tannersville in Greene County is
spearheading a pharmacy wellness initiative that could be replicable throughout the region,
which staffs pharmacies with “wellness coordinators.” This is an opportunity to Include
pharmacists in community coalitions to assess their concerns about danger and give them a
sense of community support for harm reduction strategies.
Miscellaneous issues
A lack of public transportation is cited over and over again by everyone we speak with, because
it creates huge barriers to treatment, particularly for people who may have lost their licenses.
Reaching communities that are difficult to reach is one of our largest treatment concerns.
People who are difficult to find -- such as disconnected youth -- require creative strategies to
reach them where they are. And barriers between consortium members compound the problem.
50
https://www.health.ny.gov/diseases/aids/general/opioid_overdose_prevention/docs/pharmacy_
directory.pdf.
44
Most members of our consortium have cited barriers to communication and collaboration as
their number one concern when it comes to responding to the overdose crisis. There is no
centralized place for events and information about addiction in the Catskills region. This was the
3. Recovery
In the spring of 2019, Friends of Recovery Delaware Otsego received a $350,000 grant to build
a Turning Point recovery center in the town of Delhi, the county seat of Delaware County, using
State Opioid Response (SOR) funds. FOR-DO in Delhi is a satellite of an active FOR-DO
chapter based in Oneonta, which has many programs and a vigorous staff. The Delhi branch
opened in the summer of 2019.
Samadhi Recovery Community Outreach Center in Kingston is a newly-opened recovery center

in Kingston with a Buddhism-inflected curriculum. Its executive director, David McNamara, is
eager to collaborate with regional efforts to respond to overdose and addiction. Maya
Hambright, a buprenorphine-waivered physician, is affiliated with Samadhi.
Alcohol and Drug Abuse Services of Delaware County provides some recovery services,
including after care services and specialized groups that teach recovery skills, stress
management and relapse prevention. Mary Rosenthal, who runs ADAC, is an active member of
our consortium and is a tireless collaborator for prevention, treatment and recovery services in
the region.
Rehabilitation Support Services, Inc. (RSS) offers recovery-oriented services to people with
co-conditions of both mental illness and substance abuse, including housing options,
employment opportunities and social clubs.
Mutual Aid Support Groups: There are many Alcoholics Anonymous groups that meet in the
Catskills region, but there are only four Narcotics Anonymous groups that meet in the region --
in Delhi, Stamford, Walton and Woodstock. (Source: ADAC of Delaware County.)
A lack of public transportation is cited over and over again by everyone we speak with. People
in recovery are limited from getting to their jobs, homes and support systems because of this
issue.
Scott Burrows, the coordinator of the Delaware County Drug Treatment Court, and Sylvia
Armanno, the Deputy Commissioner of Delaware County's Department of Social Services, told
us during a focus group session about the needs of people in recovery the housing was a large
issue for that population. “There are very few places people can live,” Armanno said. She
pointed out that the homeless shelter in Delaware County can only house people for less than
45
30 days. Therefore, there is a need for affordable transitional housing with adjacent accessible
transportation for use by people in early recovery throughout the Catskills region. Housing was
the third highest priority need for improving overall health in the region chosen by the Delaware
County Long Term Care Council during its Mapping and Intercepts Planning Exercise in July
2019, and was one of the priorities of focus chosen by participants in the Catskills Addiction
Coalition Summit Mapping Exercise from January 2019.
Josh Weaver, a person in recovery who volunteers with our coalition, researched various
recovery housing options in the Catskills, including a church in Fleischmanns and various
halfway houses, and has explored some potential funding options for such work. He needs help
with research and funding to keep his project moving forward.
Several programs in the Catskills are addressing the fact that there is a lack of qualified workers
in Catskills region and a high number of people in recovery who need work. These
“recovery-friendly businesses” initiatives have been started by Friends of Recovery Delaware
Otsego and the Mountaintop Care Coalition. They work with people in recovery, pairing them
with businesses that need workers. A certified recovery peer advocate supports both the
employee and the employer.
In the summer of 2019, the Catskills Addiction Coalition and the Central Catskills Chamber of
Commerce co-hosted a Recovery Friendly Businesses breakfast that recruited local business
owners to employ people in recovery. The Mountaintop Cares Coalition is working with county
labor officials on a similar program, and is collaborating with the Catskills Addiction Coalition on
the program.
Communication and outreach is a large recovery need. There is no centralized way to find
recovery resources in the Catskills, although the Delaware County Drug Use Task Force is
working on creating a pocket resource guide and Ulster County offers a similar tool. This was
the most-mentioned concern aired at the consortium’s kickoff meeting on Oct. 30, 2019.
4. Existing and possible federal, state and local resources that can be leveraged
There are many state, federal and local grant resources that can be leveraged to augment the
work of the consortium and the Catskills addiction coalition. The CAC is already the recipient of
a Robert Woods Johnson Collaborative Communities grant that explores “Recovery Friendly
Communities,” and has received funding from a variety of local sources for its series of Opioid
Summits.
National and Federal
● Centers for Disease Control and Prevention Overdose Data to Action grants -- according
to the New York State 2018 Report, these CDC grants largely funded prescription drug
46
overdose prevention and a public health crisis response project run by Health Research,
Inc.51
● Drug Free Communities Support Program Grant — typically comes out in January and
March from the Office of National Drug Control Policy and SAMHSA, 125,000 for five
years. Focus on youth substance abuse.
● Robert Woods Johnson Foundation Collaborative Communities Grants and other rural
community resources.
● The National Institutes of Health HEALing Communities Study (HCS) is using New York
State as one of its study areas, including portions of our granting areas in Ulster and
Greene counties.52
● AmeriCorps State and National Grants.
● Addressing the Challenges of the Opioid Epidemic in Minority Health and Health
Disparities Research in the U.S. (R01 and R21) -- Specifically funding “underserved rural
populations” and evaluating things like MAT in nontraditional settings, the intersection of
OUD with mental health disorders, and serving pregnant women using MAT.53
● Various SAMHSA grants, including State Opioid Response (SOR) grants.54
● Community Transportation Association of America grants.55
● Foundation for Opioid Response (FORE) grants.
● Human Resources and Services Administration (HRSA) Rural Communities Opioid
Response Implementation grants.
● National Health Service Corps (NHSC) Loan Repayment Programs and Scholarships.
● Part B of the Ryan White HIV/AIDS Treatment Extension Act of 2009.
● Many more federal grant opportunities are here:
https://www.ruralhealthinfo.org/topics/opioids/funding
New York State
● New York State Office of Drug User Health runs a network of Drug User Health Hubs
that offer a large array of harm reduction support resources, including buprenorphine,
law enforcement assisted diversion, opioid overdose prevention and aftercare and
anti-stigma practices.56
● In May 2019, Governor Andrew M. Cuomo announced $175 million in funding for the
Workforce Development Initiative (https://www.ny.gov/workforcedevelopment), which
51
“Centers for Disease Control and Prevention Fiscal Year 2018 Grants Detail Profile Report for New
York,”
https://wwwn.cdc.gov/FundingProfilesApp/Report_Docs/PDFDocs/Rpt2018/New-York-2018-CDC-Grants-
Profile-Report.pdf
52
ttps://heal.nih.gov/research/research-to-practice/healing-communities
h
53
ttps://www.ruralhealthinfo.org/funding/4364
h
54
ttps://www.samhsa.gov/grants
h
55
ttps://ctaa.org/grant-programs/
h
56
https://www.health.ny.gov/diseases/aids/general/about/substance_user_health.htm
47
includes the New York State Department of Labor offering $25 million available for
businesses to train workers and unemployed people for specific jobs.
● State Opioid Response funding through SAMHSA and NYS OASAS, some of which has
been provided to Delaware County but has not been used. (See Gaps and Opportunities
below.)
● NYS Department of Transportation has offered funding for help establishing public
transportation solutions in Delaware County.
● Tom O’Brien, a member of our consortium and the former superintendent of Roxbury
Central School was part of the Governor’s Task Force to Combat Heroin and has helpful
statewide connections that have already been quite useful to the consortium.
Local
Many local private philanthropists, small foundations and for-profit businesses can fund and
have already funded this work.
● Friends of Recovery Delaware-Otsego.

● Delaware County Drug Use Task Force: “In August of 2018, Delaware County received a
grant for $75,000 to address the opioid epidemic by increasing access to naloxone and
buprenorphine, increasing linkages to health services through harm reduction initiatives,
and improving upon data collection. In 2019, Delaware County was refunded for an
additional 3 years at $72,000 per year, focusing on enhancing community education,
promoting prevention, enabling established support networks by increasing linkages to
care, and maintaining the Delaware County Substance Use Prevention Task Force.”57
● Ulster County Opioid Prevention Task Force.
● O’Connor Foundation.
● Robinson Broadhurst Foundation.
● HCR Home Care.
c. Findings for workforce

Assessment of available relevant workforce, areas of workforce shortage, necessary
competencies to provide OUD services, estimated service demands, and gaps in the workforce.
Identity proposed evidence-based practice areas and necessary capacity building. Identify
resources that can support ongoing workforce development.
Workforce development in the Catskills region for healthcare professionals, peers and other
helping professions faces extreme barriers because of a lack of professionals willing to live and
work in a community that has a low pay scale, few cultural opportunities and no public
transportation options.
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http://delawarecountypublichealth.com/preventing-substance-abuse/
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1. Available relevant workforce
There are two board-certified addictionologists who rent office space on the Margaretville
Hospital campus and prescribe buprenorphine.
Currently, there is only one psychiatrist who works for the Department of Mental Health and this
doctor is based in Oneonta, NY. She comes to Delaware County (population of more than
46,000) only three days per week, has a caseload of nearly 2,500 and there is an approximate
wait time of five months for an appointment.
The Delaware County Department of Mental Health employs a mental health social worker and
a credentialed alcoholism and substance abuse counselor (CASAC) who hold office hours in a
rented office on the Margaretville Hospital campus every Friday.
The Margaretville Hospital School Mental Health Program employs a part-time behavioral and
psychiatric health nurse practitioner, and a part-time psychologist, a staff of three full-time
licensed clinical social workers and an art therapist.
As mentioned in our treatment section, there are eight providers with waivers to prescribe
buprenorphine in the rural Catskills region.
2. Areas of workforce shortage and gaps in workforce
There is a need for doctors, emergency medical technicians, social workers, psychiatrists,
primary care providers prescribing medication assisted treatment, mental health and substance
use counselors, therapists, and certified recovery peer advocates (CRPAs) in the Catskills
region.
Delaware County has been designated as a mental healthcare Health Professional Shortage
Area by the U.S. Health Resources and Services Administration.
According to the Robert Woods Johnson Foundation County Health rankings, Delaware County
ranks 51 out of 62 counties for Clinical Services with Mental Health Providers being 910:1
compared to 330:1 for top performers in the US and 390:1 for top performers in New York. For
social and economic factors, Delaware ranks 53 out of 62 counties.
The DSRIP PPS Compensation and Benefits Survey prepared by the Iroquois Healthcare
Association for Delaware County shows a significant vacancy rate for the following:
49
According to the Delaware County Office of Mental Health Agency Planning Survey for 2019,
the following rates the level of difficulty faced by licensed mental health (Article 31) clinic
treatment providers in the county for recruiting and retaining the following professional titles.
Rank 1 as not difficult at all, and 5 as very difficult.
Recruitment Retention:
Psychiatrists 5 3 very few available in upstate NY, especially child
LCSW positions 5 2 No available workers are applying for vacancy
Licensed Mental Health 5 5 No available workers are applying for vacancy
Practitioner positions
Ellen Stewart, a mental health counselor with the Margaretville Hospital School Mental Health
Program, says that when she refers a child to a developmental pediatrician or psychiatrist, there
is usually a six-month waiting period. “For children five and under who need assessments,
counseling and therapy, it’s almost impossible to get an appointment,” she says. “The mental
health clinic, they have to do triage, basically.”
3. Necessary competencies to provide OUD services
The rural Catskills healthcare workforce requires training in understanding and screening for
addiction, offering counseling, and awareness of area substance use treatment and recovery
services. Caseworkers who can provide support to people as they move between institutions
would also be helpful. Buprenorphine waiver training for providers and naloxone training for
community members is necessary.
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4. Estimated service demands
We expect service demands to be especially high for primary care providers, mental health
services, social workers, caseworkers and certified recovery peer advocates.
5. Evidence-based practice areas
We aim to introduce Screening, Brief Intervention, and Referral to Treatment (SBIRT) and Brief
Negotiated Interview tools to Catskills emergency department protocols, targeted naloxone
distribution and training to local first responders and emergency medical technicians, medication
assisted treatments such as buprenorphine to area healthcare providers.
6. Necessary capacity building
The Catskills region desperately needs nimble, flexible certified recovery peer advocates who
can contract with a wide variety of organizations to serve people in recovery wherever they are:
the gym, the hospital, church, school, etc. These peers can be trained locally, as can care
coordinators. The entire healthcare workforce would benefit from education about addiction and
medication assisted treatments such as buprenorphine, as well as local addiction prevention,
treatment and recovery resources.
7. Resources that can support ongoing workforce development
There is a Delaware County Workforce Task Force that is working on a SCRUBS and health
careers education and training initiative and a training program for certified nurse assistants.
UHS Delaware Valley Hospital holds a MASH Camp for students in grades 10-12 that aims to
introduce them to healthcare careers. In Ulster County, the county Workforce Development
Board and the Ulster County Office of Employment and Training offer training and services for
would-be workers. Delaware, Ulster and other regional BOCES programs provide vocational
services for students and youth, while a series of colleges SUNY New Paltz, SUNY Ulster,
Ulster BOCES, SUNY Delhi, particularly their nursing programs.
In May 2019, Governor Andrew M. Cuomo announced $175 million in funding for the Workforce
Development Initiative (https://www.ny.gov/workforcedevelopment), which includes the New
York State Department of Labor offering $25 million available for businesses to train workers
and unemployed people for specific jobs. Margaretville Hospital is interested in using such a
grant to train local emergency medical technicians.
There are many other federal, state and local workforce resources we can leverage to support
and grow the opioid use disorder workforce in the Catskills:
● National Health Service Corps (NHSC) Loan Repayment Program
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● Bureau of Health Workforce (BHW)58
● NHSC Substance Use Disorder Workforce Loan Repayment Program
● NHSC State Loan Repayment Program
● U.S. Department of Agriculture Rural Business Development Grants
● Teaching Health Center Graduate Medical Education Program
● Federal healthcare apprenticeships
● Health Resources and Services Administration (HRSA) Opioid Workforce Expansion
Program for Paraprofessionals
● HRSA Opioid Workforce Expansion Program for Professionals
● SAMHSA State Targeted Response to the Opioid Crisis (Opioid STR) Grants
● U.S. Department of Labor (DOL) Workforce Innovation and Opportunity Act (WIOA)
funding
● New York State Area Health Education Center (NYS AHEC)
● New York State Delivery System Reform Incentive Payment (DSRIP) Medicaid grants
and reimbursement policies
● Partnerships for Success and Drug-Free Communities Support Program
● State University of New York Delhi, New Paltz and Albany professional graduate
programs
● Rural Recruitment and Retention Network (3RNet)
● CDC Opioid Crisis Cooperative Agreement
● New York State Boards of Cooperative Educational Services (BOCES) -- Vocational
education programs for high school students
d. Priority setting strategy

Building concurrence within the consortium and among stakeholders for setting priorities.
Describe priority needs, issues, feasibility, and possible strategies to address these priorities.
Whenever possible, we rely on the members of our consortium to choose the projects towards
which we direct our resources. We particularly want people with lived experience to guide our
work and determine our priorities.
To this end, we have developed a prioritization strategy that uses data from surveys, group
mapping exercises and focus groups to determine which needs and gaps, as well as
opportunities and assets, are most important to our consortium and community. For a
description of the various prioritization data we have gathered from surveys, group mapping
exercises and focus groups, see Appendix A.
Once we identify the needs and gaps, and corresponding opportunities and assets, we submit
them to a modified “Critical Weighing Method” based on the one found in the Marshall Health
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Prioritization Guide.59 This allows to determine in a systematic way how important each need is
perceived by the community and whether the potential strategies to address those needs are
wanted, feasible, achievable and measurable. To see our Critical Weighing Method, go to
Appendix D.
We have applied this prioritization strategy to 25 needs and gaps identified by our analysis. To
see a full list of the identified needs and gaps and their corresponding priority rankings
according to our methodology, see Appendix E.
1. Priority Needs
We have chosen the top 10 priority needs to focus on as ranked by our methodology. For a full
list of the identified needs and gaps and their corresponding priority rankings according to our
methodology, see Appendix F.
11. Lack of communication and collaboration among stakeholders, service providers and
community members -- Priority score: 59
12. No affordable public transportation in much of the region -- Priority rank 57
13. Lack of focus on substance issues and youth, particularly “disconnected youth” -- Priority
score: 56
14. Low number of qualified workers in Catskills region; high number of people in recovery
who need work -- Priority score: 49
15. The community needs a resource to go for drug use referrals, ideally with the word
“opioid” or “drug use” in the title -- Priority score: 44
16. Stigma causes resistance to adopting harm reduction programming -- Priority score: 43
17. Certified recovery peer advocates (CRPAs) are not available easily and accessibly
throughout the region -- Priority score: 42
18. Local mental health care services don’t necessarily address substance use -- Priority
score: 40
19. No transitional affordable housing with adjacent accessible transportation available for
people in early recovery -- Priority score: 38
20. Cultural divides and a lack of understanding of conditions on the ground has tied up
$150,000 in opioid funding -- Priority score: 37
2. Priority Issues
Once we have chosen our priority needs, we group the needs and related opportunities into
related issues, each of which is assigned several “champions” and facilitators. These leaders
take responsibility for tackling each issue, becoming the co-chairs of committees and small
groups that are assigned to each issue that tackle specific, achievable projects.
59
“Opioid Response Planning: Prioritizing for Improvement,” Marshall Health Division of Addiction
Sciences in the Department of Family and Community Health, Joan C Edwards School of Medicine.
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Below are the priority issues and related projects currently being planned by our consortium:
11. Coordination and communication: Media, outreach, connection

12. Transportation: Lobbying for a public transportation system in Delaware County
13. Youth Engagement: Youth center, certified recovery peer advocates
14. Recovery-Friendly Businesses: certified recovery peer advocates, business outreach
15. Criminal Justice: Law Enforcement Assisted Diversion, substance use help line, re-entry
program
16. Stigma and public education about addiction
17. Mental Health: Margaretville Hospital School Mental Health program
18. Housing: Recovery-friendly housing and transportation
19. Pharmacies: Holistic treatment and recovery services
20. Treatment: Drug use education and screening, MAT induction into local emergency
rooms, increasing access to naloxone, harm reduction, substance use clinics at local
hospitals
3. Priority Feasibility
We are using the PEARL Test from the Marshall Health Prioritization Guide60 to ensure that the
issues we have chosen are feasible according to five metrics: Propriety, Economics,
Acceptability, Resources and Legality. All of our priorities have PEARL scores of 1.
For each factor, assign a ‘1’ (yes, the issue is feasible for this factor) or a ‘0’ (no, the issue is not
feasible for this factor). The final PEARL score is calculated by multiplying the scores of all 5
factors together. A PEARL score of 0 doesn’t automatically disqualify us from pursuing the issue
as a consortium, but it does mean we must mitigate the feasibility issues before moving forward.
• Propriety: Is a plan to address the issue suitable for the community/county? Is this the best
group to address the issue?
• Economics: Does it make economic sense to address the issue? Are there economic
consequences of ‘not’ addressing it?
• Acceptability: Will the community accept working on this issue? Is it wanted?
• Resources: Is funding available or potentially available for the interventions needed? Are other
resources needed and available?
• Legality: Do current laws allow the needed activities to be implemented? Does policy
development need to happen first?
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4. Possible Strategies to address priorities
The possible strategies to address each priority need are listed in the next section.
E. Discussion / Conclusion: Gaps and Constraints / Assets and

Opportunities
These are the 10 top priority needs chosen by our consortium. We group priority gaps and
needs with their corresponding opportunities and potential strategies for meeting those needs.
Gap 1: Lack of communication and collaboration among stakeholders, service providers and
community members
Reaching communities that are difficult to reach is one of our largest concerns. Particularly,
people who are difficult to find -- such as disconnected youth -- require creative strategies to
reach them where they are. We haven’t yet cracked the code that allows all consortium
members to feel included and clued in to various consortia happenings. Most members of our
consortium have cited barriers to communication and collaboration as their number one concern
when it comes to responding to the overdose crisis. There is no centralized place for events and
information about addiction in Delaware County, or in the Catskills region. This was the
Opportunity: Create a communications plan for the Catskills Addiction Coalition that
creates a feeling of buy-in and connection among consortium members and the larger
community. The Catskills Addiction Coalition has brought together a large number of disparate
sectors that don’t normally talk to each other. It can use these connections to foster
communication, research and sharing of learnings to educate our community and agree on facts
on the ground together. There is desire in our community to know what is happening and to
reach out and learn from each other. Explore digital (e-newsletters, Slack, Facebook groups,
shared Google Calendars) and old-fashioned (in-person meetings, potlucks, living-room
gatherings) methods of creating networks and keeping each other informed. We have
experimented with a variety of strategies, including far-flung meeting attendance, regular email
newsletters, casual conversations with the Project Director, physical presence at a variety of
events where conversations can happen, weekly phone check-ins, public media appearances,
and more. Develop ways to measure the impact of various communication strategies. The
Catskills Addiction Coalition, which is already connecting disparate silos of addiction information
in the region, can host this calendar with the help of partners recruited by the Delaware County
Drug Use Task Force.
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Gap 2: No affordable public transportation in much of the region
Delaware County is one of only two counties in New York State without public transportation,
and this lack of easy and affordable ways to get around disproportionately affects prevention,
treatment and recovery efforts in the region. From a prevention perspective, people have less
access to healthcare, recreation, and work; the lack of transportation creates huge barriers to
treatment, particularly for people who may have lost their licenses; and people in recovery are
limited from getting to their jobs, homes and support systems because of this issue.
Opportunity: Stakeholders in every sector are eager to create more and better forms of public
transportation in the Catskills, and such a system would likely be grant funded and would
consolidate redundant, costly resources. Leadership and persistence, as well as public
pressure, are key to making more transportation solutions to serve our focus populations.
Gap 3: Lack of focus on substance issues and youth, particularly “disconnected youth”
no point during the months of meetings and conversations I’ve had has the topic of treating
youths who are using substances come up. Yet the majority of the people in recovery I have
spoken with began using substances in high school or younger. The prevention resources in the
Catskills focus almost entirely on in-school interventions, a focus that completely misses
“disconnected youth,” who are not affiliated with local schools. Middle school children especially
need activities, because they are too young for sports but too old for the CROP after-school
program. Many members of our consortium are particularly concerned with offering mental
health services to disconnected youth, but also youth engagement programs. The concept of a
youth mentoring program or community youth center came up more often than any other idea at
the 2019 Catskills Addiction Coalition summit.

disconnected youth, in the Catskills, by combining youth engagement projects like a
youth center or a mentoring program with substance use and mental health resources
such as counselors and certified recovery peer advocates. Use the Margaretville Hospital
School Mental Health Program, which offers mental health counseling services to the families of
children in the schools, as a base upon which to expand. Robbie Martin, who runs the program,
has noted the problem of “disconnected youth” for her program and wants to expand her
in-school offerings to reach community members who are not in school -- for example, by
supporting after-school activities that are open to all community members and caseworker
services for the families of children in the school. Middle-school aged tweens should be a
particular focus on this programming. New York City has done a considerable amount of policy
work on the topic of disconnected youth, and our consortium can benefit by studying policies
and programs that have worked and may be transferable to a rural region.61
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Gap 4: Low number of qualified workers in Catskills region; high number of people in recovery
who need work.
Opportunity: Several programs in the Catskills are addressing the fact that there is a lack of
qualified workers in Catskills region and a high number of people in recovery who need work.
These “recovery-friendly businesses” initiatives have been started by Friends of Recovery
Delaware Otsego and the Mountaintop Care Coalition. They work with people in recovery,
pairing them with businesses that need workers. A certified recovery peer advocate supports
both the employee and the employer. In the summer of 2019, the Catskills Addiction Coalition
and the Central Catskills Chamber of Commerce co-hosted a Recovery Friendly Businesses
breakfast that recruited local business owners to employ people in recovery. The Mountaintop
Cares Coalition is working with county labor officials on a similar program, and is collaborating
with the Catskills Addiction Coalition on the program. These programs need paid staff and
resources to thrive.
Gap 5: The community needs a resource to go for drug use referrals, ideally with the word
“opioid” or “drug use” in the title.
Without advertising, our office has begun receiving calls from people who want general
information and referral services about addiction and substance use issues. Since September
2019, we have received five such calls, including a referral from a local provider, a woman who
had been discharged from Schoharie County and needed help; a call from hospital employee
who had a friend with a child with a substance use disorder; a call from the stepmother of that
same person, and a call from a woman who was leaving inpatient drug rehab and who needed a
referral. Margaretville Hospital has received more inquiries that have not made it to our desk:
nurses who staff the nursing station after-hours say that they regularly receive after-hours calls
from people inquiring about opioid services and referrals and have no place to send them, and
Stacy Wright, the office coordinator at the physical medicine and rehab office, says that she,
too, gets unsolicited calls about addiction, simply because the word “rehab” is in her office’s
name. Our naloxone trainer from OASAS told us that overdose survivors sometimes call their
local hospital or emergency room for information about recovery and lists of resources and
detoxes. Margaretville Hospital currently does not have resources to respond to such inquiries.
Opportunity: Establishing a regional help line for drug use referrals that can be accessed by a
range of hospitals, social service organizations and law enforcement professionals. Drug use
hotlines and help lines already exist in Ulster and Sullivan counties. Ulster County created such
a hotline in December 2019 by creating a voicemail located in the Sheriff's Office dispatch office
that emails a team of police officers when it gets a call, according to Sergeant Chad Storey at
the Ulster County Sheriff's Office. They plan on training several dispatchers to answer the
hotline live in the future, but for now they've spun it up this way. Sullivan County also operates a
drug use hotline that provides referrals. There is interest from several stakeholders in Delaware
County for establishing one here.
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Gap 6: Stigma causes resistance to adopting harm reduction programming
The Catskills’ community’s cultural approach to and perceptions of addiction and recovery
cause a tremendous amount of resistance to creating, adopting and sustaining programs that
can help people people who use drugs and people in recovery. Cultural and institutional
resistance to a harm reduction approach to reducing morbidity and mortality from substance use
is rampant, subtle and powerful. This makes it difficult to implement overdose response
strategies even with time, money and resources available. Cynthia Heaney, the Delaware
County Director of Community and Mental Hygiene, says that stigma about substance use and
mental health has been a pervasive and confounding problem for her work. “When I first came
on board, I said, ‘We’ve got to do something with stigma reduction,’” she says. Heaney has run
a small pilot project funded by a SAMHSA grant to hire Jessica Vecchione, a local filmmaker, to
produce a series of videos and accompanying forums featuring people in recovery to combat
stigma, but the funding for that project has run out.
Opportunity: Cultural education/stigma are a huge opportunity in the Catskills. More funding
can be put into Jessica Vecchione’s existing homegrown education and outreach projects. That
work has already been approved by the Delaware County Board of Supervisors, the county’s
conservative governing body. This is a tremendous amount of buy-in in a conservative rural
county. The consortium could then use this anti-stigma storytelling content to partner with local
community resources like food pantries, schools and gyms, which would become conduits for
education for the general public and platforms to build trust with people who use substances.
Gap 7: Certified recovery peer advocates (CRPAs) are not available easily and accessibly
throughout the region.
Delaware-Otsego (FOR-DO) is hoping to staff peers at Margaretville Hospital, but bureaucratic
barriers to these partnerships such as review by legal departments and funding must be
overcome first. It is particularly notable that the Delaware County Drug Court lacks a
recovery-based model of care, isn’t integrated into the healthcare system, and doesn’t
collaborate with FOR-DO, the local recovery organization, to have a peer support its
participants.
Opportunity: Explore flexible funding and collaboration models with peer agencies. Work
with Samadhi and FOR-Do to staff peers in accessible locations or have them respond in an
“on-call” manner when needs arise, in partnership with local emergency departments, private
businesses and police departments. This is an opportunity to explore flexible funding and
collaboration models with peer agencies. We would like to work with Samadhi and FOR-DO to
staff peers in accessible locations or have them respond in an “on-call” manner when needs
arise, in partnership with local emergency departments, hospitals, private businesses, police
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departments. It is also worth considering obtaining funding and education for local drug
treatment courts to use peer services.
Gap 8: Local mental health care services don’t necessarily address substance use
The Margaretville Hospital School Mental Health program doesn’t explicitly offer substance use
The school mental health is popular and is receiving requests from other school districts to
expand, but its staff are too busy to grow the program without outside help. But its staff
acknowledge that substance use issues are appearing in the lives of the children they work with.
Opportunity: We can leverage mental health and substance use resources to complement
each other and collaborate. With funding for more counselors who can focus on substance use
in children and families, the school mental health program could be expanded to include
substance use treatment. With additional personnel, the school mental health program could
expand into substance use treatment and casework support for families and prevention
activities for the community. A grant could pay for an external evaluator to assess the program
and show the impact it is having on kids. We could collaborate with other area mental health
resources, including the Delaware County Mental Health Clinic and Rehabilitation Support
Services, Inc., both of which offer services for mental health and substance use issues. Perhaps
a combined substance use and mental health peer could work in the school system. We can
leverage mental health and substance use resources to complement each other and
collaborate. We could encourage combined mental health and substance use approaches to
community care with innovative job descriptions, shared work and combined training.
Gap 9: No transitional affordable housing with adjacent accessible transportation available for
people in early recovery.
us during a focus group session in the fall of 2019 about the needs of people in recovery the
housing was a large issue for that population. “There are very few places people can live,”
Armanno said. She pointed out that the homeless shelter in Delaware County can only house
people for less than 30 days. Therefore, there is a need for affordable transitional housing with
adjacent accessible transportation for use by people in early recovery throughout the Catskills
region. Housing was the third highest priority need for improving overall health in the region
chosen by the Delaware County Long Term Care Council during its Mapping and Intercepts
Planning Exercise in July 2019, and was one of the priorities of focus chosen by participants in
the Catskills Addiction Coalition Summit Mapping Exercise from January 2019.
Opportunity: Josh Weaver, a person in recovery who volunteers with our coalition, researched
various recovery housing options in the Catskills, including a church in Fleischmanns and
various halfway houses, and has explored some potential funding options for such work.
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Gap 10: Cultural divides and a lack of understanding of conditions on the ground has tied up
$150,000 in opioid funding
According to Robert Kent, the general counsel for the New York State Office of Addiction
Services and Supports (OASAS), while Delaware County is eligible to access up to $400,000 in
State Opioid Response (SOR) funding, the county has not accessed those funds.
When I spoke with Cynthia Heaney, the Delaware County Director of Community and
Mental Hygiene, whose office is the gatekeeper for at least some of these funds, she told me
that OASAS is not recognizing rural realities on the ground that prevent the county from easily
using these funds.
Her department was offered $150,000 in State Opioid Response (SOR) funding earlier in
2019 to hire Certified Recovery Peer Advocates (CRPAs), purchase vehicles and telemedicine
equipment, to provide transportation for patients to opioid use disorder and to attract and pay for
waivered buprenorphine providers. She declined to accept the funds because she was unable
to use them for multiple reasons, she says:
● The short time frame. The money had to be spent by September 30, 2019, while her
budget planning for adding new positions to her agency must be done a year in
advance.
● Peers (CPRAs) could only be hired directly, not contracted. The funds could not be used
to contract with peers from an existing peer agency, Friends of Recovery, because
restrictions on the funding only allow for the peers to be hired directly by the agencies so
that their services can be billed to Medicaid.
● Concerns about cost, ongoing funding and liability for the county.
● General rigidity of the parameters of the funding, which don’t recognize rural needs. “The
reality is that I don’t think the best place for a peer is as a county employee in a
brick-and-mortar clinic,” she says. “We’re not flexible. We work 9 to 5 Monday through
Friday, and people that need help in addiction need help at additional times. You need
peers who have the flexibility to go to the emergency room; you need peers who have
the flexibility to go where folks are.”
● Compounding the problem is that Delaware County has been shamed publicly for its
concerns about spending this money, Heaney says.
Opportunity: Change requirements on spending State Opioid Response funds to allow

rural counties like Delaware more flexibility. With help, more active listening and more
sensitivity to unique rural and cultural needs, our consortium could overcome the barriers to
using SOR funding and perhaps other funding as well. A dedicated group of people who could
consult with the state and provide support to the county and local agencies would go a long way
towards smoothing the way for collaboration.
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Appendix A: Needs Assessment Methodologies
“Living in Recovery” Survey
We have developed a “Living in Recovery” survey that, among other things, asks respondents
to select categories of local prevention, treatment and recovery services that were “challenges”
and that were “helpful” to their recovery. We expect patterns to emerge in the results that will
help us address the most challenging issues and boost the most helpful supports that already
exist in the community. The results of this survey will be added to this Needs Assessment in an
Addendum in the spring of 2020.
2019 Catskills Addiction Coalition Summit Mapping Exercise

In January 2019, the Catskills Addiction Coalition conducted a daylong workshop with over 100
people attending that broke into small brainstorming groups which chose eight priority
objectives, which were published in a “Community Action Plan” in March 2019. (See Appendix
D.)
An analysis of the Community Action Plan from 2019 shows that several ideas emerged multiple
times in different groups. The concept of a youth mentoring program or community youth center
came up the most often, in four different small groups. The concept of combating stigma around
substance use and mental health came up three times in three separate groups. Workforce
development, housing, telehealth, increasing the number of certified recovery peer advocates
and transportation all came up multiple times in multiple groups.
Top issues chosen by the group:

Youth engagement
Stigma
Mental health
Workforce development
Housing
Telehealth
Certified recovery peer advocates (CRPAs)
Transportation
Mapping and Intercepts Planning Exercise, Long Term Care Council, 7/31/19
In July 2019, Julia Reischel participated in Long Term Care Council community health Mapping
and Intercepts Planning Exercise that resulted in the council choosing four areas of focus to
improve overall health in Delaware County. The four “intercepts” chosen by the group were, in
order of priority, Transportation, Aid Workforce Shortage, Accessible Housing and Socialization
& Physical Activities.
Intercept 1. Transportation:
61
Intercept 2: Aid Workforce Shortage:
Intercept 3: Accessible Housing
Intercept 4: Socialization & Physical Activities
Readiness Screening Framework from the Wandersman Center with the Catskills
Addiction Coalition’s Steering Committee on October 6, 2019
The group listed finding relevant local quantitative data, persons with lived experience,
documenting Opioid Use Disorder consequences, and data analysis regarding our populations
of focus as challenging areas for us.
Evidence-Based Strategies: What’s Working in the US -- RCORP Needs Assessment Tool

to measure Consortium and Community Readiness
Our team ranked the following evidence-based strategies as having the most awareness and
understanding and buy-in from the community. The higher the score, the more important and
feasible the strategy.
Medication Assisted Treatment

Score: 31
Targeted Naloxone Distribution

Score: 30
Buprenorphine MAT in local Emergency Departments

Score: 27
Needs Assessment at Margaretville Cauliflower Festival — 5 people participated

Public Transportation: 1
Local Treatment Services: 1
Building Local Employment: 1
Recovery Coaches: 1
Focus Groups
We conducted eight focus group meetings in the fall of 2019 where community members and
stakeholders who were interested in specific topics gathered to discuss specific topics related to
addiction. At each of these meetings, we asked the attendees to answer the question: “What do
you need?”
Focus Group: Needs Assessment at Margaretville/Pine Hill Rotary Meeting — 12 people

attended
Youth Mentoring program: 4
Education about Recovery and Stigma: 3
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Recovery Coaches: 1
Criminal Justice Reform: 1
Needs Assessment at Margaretville Cauliflower Festival — 5 people participated

Public Transportation: 1
Recovery Coaches: 1
Focus Group: Needs Assessment at Margaretville/Pine Hill Rotary Meeting — 12 people

attended
Youth Mentoring program: 4
Education about Recovery and Stigma: 3
Recovery Coaches: 1
Criminal Justice Reform: 1
Focus Group: Catskills Addiction Coalition kickoff meeting, Oct. 30, 2019 We went around
the room and asked each participant “What do you need?” This yielded a great discussion that
lasted for an hour. Briefly, here are everyone’s answers:
○ Rina Riba: Collaboration

○ Kim Lacey: Wants to help
○ Kali Murphy/Delmar: Communication, a lack of duplication of effort; more
coordinated data-gathering about overdoses
○ Amy Smith: Can help loop in hospital response
○ David McNamara: Support for and use of peers
○ Tom O’Brien: “Reality” — projects that can work in the real world
○ Mary Rosenthal: Communication, not duplicating efforts
○ Arnie Schwartz: Local resources for youth, transportation
○ Jonathan Gross: Networking, communication. He discussed the Mountaintop
Advocacy Coalition’s work in Greene County and how it can dovetail with the
CAC’s work. They have a wellness pharmacy project, a recovery workforce
project and public outreach projects. Last week, they held a panel and screening
of Jessica Vecchione’s movie “Smacked” that drew 200 people.
○ Drew Brenner: Strengthening relationships, boosting the economy, addressing
poverty
○ Kenneth Oclatis: Needs to know what role the community wants the hospital to
play
○ Linda Webb Varian: Communication
○ Diana Mason: Eyes on the prize, improving access to prevention
○ Mark Pohar: Guidance from the community on what role the hospital should play
63
○ Randy Moore: Offered support for pharmaceutical needs
○ Judy Williams: Ways to address sexually transmitted diseases, including making
condoms more available
○ Judy Green: Said that she had a personal connection with drug use in her family
○ Carol Bouton: Wants to recognize issues opioids cause in families
○ Chad Storey: Described the ways the ORACLE program of the Ulster County
Sheriff’s Office is working to address the opioid epidemic, including outreach to
the public about signs of drug addiction, a hotline for folks who need help that will
reach teams of police, social workers and peers, and other measures.
○ Rebecca Manning: Was curious about creating more local employment, youth
engagement programs, recovery coaches, and wants to offer recovery-oriented
programming at the gym. Talked about running a recovery triathlon group.
○ Kayliegh Riordan: Mentioned that she had used triathlon training as part of her
recovery. Said that she needs a willingness to look at new ideas, to grow as a
group, to look at what we think won’t work with new eyes.
○ Scott Tyree: Communication, and collaboration with other groups and
organizations
○ Emily Taggart: Communication
○ Karen Driskill: Wants to learn how to advocate for patients in recovery.
○ Scott Burrows: Housing and transportation
○ Susan Linn: Hitting the deliverables of the HRSA grant.
○ Jessica Vecchione: Needs funding and support for her films, which are an
education tool.
○ Megan: Make use of the Central Region Prevention Resource Center, Prevention
Network.
○ Kurt Grovenberg: Wants us to improve the way we handle pain management.
Top two needs mentioned:

1. Communication and Collaboration: 7 mentions
2. Transportation: 2 mentions
Focus Group: Delaware County Drug Treatment Court and DSS

Need decided on by consensus: Housing
Focus Group: Delaware County Sheriff’s Office and social services -- Criminal Justice
Needs mentioned: Police safety, help line
Focus Group: Delaware County transportation stakeholders: DSS, nonprofits, ARC of

Delaware County, church groups, Office for the Aging, GetThere Call Center
Needs mentioned: Collaboration, public transporation
64
Focus Group: Margaretville Central School, Maverick Family Counseling, Catskill
Recreation Center
Needs mentioned: Community youth center, resources for middle-school children, mental health
services
Trial naloxone training: December 3, 2019 at Margaretville Hospital

Our team worked with hospital staff and the New York OASAS naloxone training program to
bring a naloxone training to the hospital as a data-gathering exercise, to gauge how to advertise
and promote such trainings, whether there was an audience for them, and how well the
messaging was received. We found the following:
● Advertising and promotion: A week of facebook ads, a flyer printed in the Catskill
Mountain News, posts on CAC and JR and KL Facebook posts. Flyers put up around
Margaretville, Delhi, Walton and Downsville. Mass email to hospital staff a week before,
word of mouth and Facebook were the most effective forms of promotion. No one cited
advertising as a reason they came, and one attendee said that she didn’t “hear anything
about it” beforehand.
● Attendance: Eight attendees, not including CAC staff
● Affiliations of attendees:
○ 2 — Mountaintop Cares Coalition
○ 1 — Margaretville Fire Department
○ 3 — Margaretville Hospital
○ 1 — Roxbury Central School
○ 1 — Catskill Recreation Center
● How they heard about the training:
○ 2 — heard about it at work at Margaretville Hospital
○ 2 — heard about it directly from Julia Reischel, MH employee
○ 2 — heard about it from the Mountaintop Cares Coalition, probably via Facebook
○ 1 — heard about it from Susan Linn, MH employee
○ 1 — heard about it from a friend
● Engagement: The training went well. The audience was engaged and interested and
asked relevant questions, and the trainer seemed especially pleased that when she
asked if anyone was forced to be there by their job, nobody raised their hands. This
attendance shows that there is an interest and a need for these trainings in the
community.
● Impact: Christee Thomas, one of the people who attended the training, passed the info
along to her volunteer fire departments in Pine Hill (Chief Orville Smith), Oliverea (Chief
Chuck Perez) and Mount Tremper. They are planning to contact OASAS to do a
naloxone training for them. Becky Manning, the director of the Catskill Recreation
Center, is also planning a naloxone training for her staff.
● Gaps and Opportunities learned from naloxone training:
○ OASAS trainer mentioned that few people are aware of the 2016 CDC guidelines
for prescribing opioids — nobody in the room was aware of these. Opportunity for
education.
65
○ People at training knew nothing about fentanyl, including basic facts about its
prevalence, the difference between illicit fentanyl and prescribed fentanyl, etc.
Opportunity for education.
○ OASAS trainer mentioned that there is no state-to-state tracking of prescriptions,
so folks can shop for pills across state lines. Opportunity for regional
collaboration?
○ Despite NYS Take-back Law, local pharmacies don’t necessarily understand
these rules or have ways to take back drugs. The Delaware County Sheriff’s
Office has a drug take-back box, but it is underpublicized. The Margaretville
Hospital Pharmacy has a take-back box, but it is only available during business
hours.
○ CVS pharmacy has stigma. 12/3/19, I asked at CVS pharmacy in Margaretville
whether I could return opioid drugs, and tech and male pharmacist responded
that “NY State Law prohibits use from taking back any prescription drugs.” This is
in direct conflict with the NYS OASAS trainer’s info about pharmacies which she
presented in a naloxone training on 12/3/19 to a group at Margaretville Hospital,
where she said that it is NYS law that pharmacies are “REQUIRED” to take back
drugs, and that CVS Pharmacies in particular have committed to doing this. She
is right; Chapter 120 Laws 2018,
https://www.health.ny.gov/professionals/narcotic/drug_take_back.htm:
○ Lots of misinformation and misunderstanding about why and how overdoses
happen, and even what they are. No one at the training knew that taking many
drugs at the same time increases a change of overdose.
○ OASES trainer didn’t seem well versed in dealing with rural first responders who
don’t have many resources and might be volunteers. There is an opportunity to
tailor trainings for more rural areas.
○ The OASAS trainer suggested that everyone being discharged from treatment or
jail be issued a naloxone kit to prevent overdose, because folks are at particularly
high risk of overdosing when they return home from jail and/or rehab. Opportunity
for naloxone trainings in jails? At “coming home centers”?
○ OASAS trainer referred to many suicide prevention resources, but there aren’t
that many in Delaware County. Opportunity to meld addiction, mental health and
suicide resources together?
○ In a rural setting where help takes a long time to come and first responders are
often volunteers, who can stay with an overdosing person for the full three to four
hours needed?
○ Fears about liability make it difficult for local first responders to adopt harm
reduction measures. For example, Nelson Delameter, the Margaretville Fire
Department Chief, wants to know two things before allowing his volunteers to do
a formal naloxone training. 1) He wants a specific state entity to tell him that his
first responders will be covered by laws that will prevent them from having liability
in case a narcan administration goes wrong. 2) He wants to know whether
workers comp will cover injuries to volunteers who administer naloxone.
66
○ Nelson Delameter, the Margaretville Fire Department Chief, says that often the
NYS Troopers on a scene will aggravate overdose survivors. Opportunity to train
state police on how to manage overdoses more helpfully
○ The OASAS trainer suggests that overdose survivors call their local hospital or
emergency room for information about recovery and lists of resources and
detoxes. Margaretville Hospital currently does not have such a list. Opportunity to
make a list of referrals that we can share as a team.
○ There is a pervasive idea that overdose survivors, once revived, will attack first
responders for “ruining their high.” The trainer says that this has never happened
to her. We need more education about this kind of thing.
○ OASAS trainer said that hospitals and individuals can become Opioid Prevention
Programs (OPP) and can sign up to distribute naloxone for free. According to the
OASAS trainer, the only OPP signed up in Delaware County is the Village of
Delhi Police Department. This is an opportunity to distribute free naloxone in the
region, and to coordinate existing efforts, like FOR-DO and others.
https://www.nyoverdose.org/ http://www.thepointny.org/
67
Appendix B: Living in Recovery Survey
The text of our December 2019 “Living in Recovery” survey. The survey will be disseminated
from December 2019 through January 31, 2019. Participants are entered into a lottery to
receive $10 gift cards. The survey is available online here:
https://docs.google.com/forms/d/e/1FAIpQLSdw5S73VlmVsGOJ50bg-KWsGVAkEZ144qo8HCw
hxav1vRYbwg/viewform?vc=0&c=0&w=1
Living in Recovery Survey

We need your help! Welcome to the Catskills Addiction Coalition (CAC) Living in Recovery
survey. This survey will take 10 minutes, and will help our coalition learn more about the needs
of local people living in recovery. With your help, we will be able to create make our Catskills
communities more recovery-friendly.
Consent Form
The purpose of the following short survey is to gather information from those of you who are in
active recovery from addiction, as there is little information on recovery available to providers,
policy makers, or the recovery community. If you are living in active recovery from alcohol or
other substances, please take the time to answer the questions below. Your participation will
require approximately 10 minutes and is completely voluntary. There are no known risks
associated with this survey, and you may choose to withdraw at any time. Your responses will
be kept strictly confidential-we are not collecting names or email addresses. Any report of this
research that is made available to the public will not include any individual information by which
you could be identified. If you have questions or concerns, you may contact the following
individuals for assistance:
Julia Reischel, Project Director Catskills Addiction Coalition Rural Communities Opioid
Response Program, Margaretville Hospital, Member of the Westchester Medical Center Health
Network, 42084 State Highway 28 | Margaretville, NY 12455 | (O) 845.586.2631 ext. 3233
julia.reischel@hahv.org
Kimberly Lacey, Administrative Assistant, Catskills Addiction Coalition Rural Communities

Opioid Response Program Margaretville Hospital, Member of the Westchester Medical Center
Health Network, 42084 State Highway 28 | Margaretville, NY 12455 | (O) 845.586.2631 ext.
3114 Kimberly.lacey@hahv.org
Please feel free to print a copy of this consent page to keep for your records. Clicking the "Yes"
button below indicates that you are consenting to participate in this survey. Thank you for
participating in our survey. Your feedback is important.
1. Do you agree to the above terms? By clicking Yes, you consent that you are willing to answer
68
the questions in this survey. * Mark only one oval.
Yes
No
2. How long have you been in recovery as you define it? *

Mark only one oval.
Less than 1 year
1-5 years
5-10 years
10-20 years
Greater than 20 years
3. Which of the following were challenges or problems for you when you first went into
recovery?
Check all that apply.
Getting a job
Housing/a place to live that is recovery friendly
Support from your family
Support from friends/chosen family
Access to medication for addiction treatment (Suboxone, methadone, etc)
Access to a twelve-step program such as Alcoholics Anonymous or Narcotics Anonymous
Access to other kinds of mutual aid groups such as All Recovery or SMART Recovery
Substance-free recreational opportunities
Transportation
Access to legal services/help with navigating the court system
Access to other recovery/advocacy services (Friends of Recovery, Center for Independent
Living, Suicide Prevention Network of Delaware County)
Access to social services and supports (ADAC, DSS, WIC, etc)
Access to a primary doctor
Access to a primary care provider who is not a doctor
Access to mental health counseling or therapy
Access to pain management
Pain management issues
Challenges of self-esteem/self-worth/spirituality
Custody/parenting issues
Access to court
Other:
4. At what time in your recovery did you feel ready for employment? *
Mark only one oval.
Zero to six months
Six to 12 months
69
One to 3 years
Three to 5 years
Other:
5. Would you consider steady employment that provides a living wage to be a support for your
recovery? * Mark only one oval.
Yes
No
Other:
6. Which of the following resources were/are helpful to you during your recovery? (Check all that
apply) * Check all that apply.
Access to mental health services
Peer advocates/Recovery coaches
Faith-based organizations
Access to treatment for substance use disorder
Safe addiction withdrawal/management of withdrawal
12 step organizations
Recovery houses/homes/facilities
Business that will hire people in recovery
Exercise
Alcohol or drug free recreational activities/hobbies
Medication assisted recovery (MAT therapy)
Non-faith based organizations
Getting a job
Enrolling in school/continuing my education
Hobbies
Family
Friends/chosen family
Volunteering
Other:
7. What event(s) caused you to begin the process of recovery? Check all that apply. *
A realization that I couldn't reach my full potential with continued use
Overdose
Arrest
Incarceration
Hospitalization
Got fired/suspended at work
Homelessness
Lost custody of children (other than through divorce)
Debt/bankruptcy
70
Was a victim or perpetrator of domestic violence
Contracted an infectious disease
Lost or suspended driver's license
Lost professional or occupational license (i.e. Medical/nursing license, contractors license,
beautician's license, etc.)
Other:
8. Have you been treated with medication for substance use disorder? (i.e. Methadone,
Suboxone,
Vivitrol, etc.) * Check all that apply.
Suboxone
Methadone
Vivitrol
Other:
9. Which local hospital system have you used during your recovery for substance use
treatment?
Check all that apply. * Check all that apply.
O'Connor Hospital in Delhi
Delaware Valley Hospital/UHS in Walton
Ellenville Regional Hospital
Albany Medical Center
Kingston Hospital/HealthAlliance
Bassett Medical Center in Cooperstown
Community-based medical providers (not providers in a hospital)
Other:
10. What health insurance providers do or did you use to access recovery healthcare? Please
check all that apply. * Check all that apply.
Health insurance through an employer
Health insurance through a family member
Health insurance that I purchased through the New York State Health Plan Marketplace
Medicaid
I paid for recovery services without help from health insurance
Other:
11. Do you use tobacco products? (i.e. Cigarettes, e-cigarettes, snuff, chewing tobacco, etc.) *
Cigarettes
Snuff
Chewing tobacco
E-cigarettes/vaping
71
12. How would you describe your physical health? *
Mark only one oval.
Excellent
Very good
Good
Fair
Poor
13. Do you have a medical provider you can go to that you trust? *
Mark only one oval.
Yes
No
14. How would you describe your mental/emotional health? *

Mark only one oval.
Excellent
Very good
Good
Fair
Poor
15. What kinds of mental health or emotional health resources would be helpful to you in your
recovery? Please check all that apply. * Check all that apply.
Local psychiatric providers who can prescribe medication
Local mental health counseling services that provide therapy
Local peers who have lived experience with recovery
Local peers who have lived experience with mental health issues
Religious and spiritual resources
Other:
16. Are you currently receiving treatment for mental health or emotional health issues? (i.e.
therapy,
counseling, medication?) Please check all that apply. * Check all that apply.
Yes
No
Other:
17. Do you ever have trouble keeping your physical or mental health or counseling
appointments?
If so, what supports would assist you in attending these appointments? *
72
18. If you are involved in the legal system, do you ever have trouble keeping your court or
probation
appointments? If so, what supports would assist you in attending these appointments? *
19. Do you have stable housing? If not, what support would assist you in obtaining stable
housing?
20. What kind of housing resources do you need to help with your recovery? Please check all
that
apply. * Check all that apply.
Free housing
Affordable rental apartments
Recovery-friendly housing (ie, non-substance housing)
Short-term housing (more than 30 days to less than six months)
Housing for six months to a year
Long-term housing
Housing with recovery support on-site (mutual aid groups, certified recovery peer advocates,
counseling)
Other:
21. Do you have consistent and reliable access to transportation? (i.e. via car, public
transportation,
or other.) If not, what support would assist you in accessing transportation? *
22. Which kinds of transportation resources would be helpful to your recovery? Please check all
that apply. * Check all that apply.
Scheduled public transportation to major nearby cities
Scheduled public transportation on major roadways in my region
Scheduled transportation to nearby town centers
Employer-sponsored transportation to and from my job
On-call private transportation (taxis, Uber, volunteer driver networks)
Carpooling to work, school, court, special outings
Other:
23. Which of the following groups of people do you feel treat you with respect and
consideration?
Please check all that apply. * Check all that apply.
Healthcare providers
Pharmacists
Teachers and school staff
Family
Employers
Friends
73
Neighbors
The recovery community
Police
Court system
Probation and parole officers
Emergency room providers
Social services providers
First responders
Community members
Elected officials and policymakers
Clergy/pastors/faith leaders
Peer Advocate/Recovery Coach
Sponsor
Other:
24. What is your age? *
25. How old were you when you first began using
drugs or alcohol? *
26. What is your ethnicity? (Select all that apply) *

American Indian or Alaskan Native
Asian or Pacific Islander
Black or African American
Hispanic or Latino
White/Caucasian
Prefer not to answer
Other:
27. How do you identify your gender? *
Mark only one oval.
Male
Female
Transgender
Nonbinary
Prefer not to answer
Other:
28. In which county do you reside? *

Mark only one oval.
Delaware
Greene
74
Otsego
Schoharie
Sullivan
Ulster
Other:
29. Are you now married, widowed, divorced, separated, never been married, or are in a
supportive
relationship as you define it? Please check all that apply. * Check all that apply.
Married
Widowed
Divorced
Separated
Non-married long-term partnership
Single
Other:
30. What is the highest level of school you have completed or the highest degree you have
received? * Mark only one oval.
Some school K-12
High school degree or equivalent (i.e. GED)
Some college but no degree
Associate degree
Bachelor degree
Graduate degree
Other:
31. Which of the following categories best describes your employment/education status? Check
all
that apply. * Check all that apply.
Employed working full-time
Employed working part-time
Not employed, looking for work
Not employed, NOT looking for work
Retired
Disabled, unable to work
In school full-time
In school part-time
Volunteering
32. Have you served in the military, active or reserve? *

Mark only one oval.
Yes
75
No
Other:
33. Would you be interested in being involved in efforts to prevent substance use disorders
and/or
support people in recovery? If so, please contact the Coalition for further information at
Catskillsaddictioncoalition@Gmail.com * Mark only one oval.
Yes
No
76
Appendix C: Catskills Addiction Coalition Community Action Plan
77
78
79
80
81
82
Appendix D: Prioritization Strategy
The Catskills Addiction Coalition has developed a modified “Critical Weighing Method” based on
the one found in the Marshall Health Prioritization Guide.62 This prioritization strategy allows to
determine in a systematic way how important each need is perceived by the community and
whether the potential strategies to address those needs are wanted, feasible, achievable and
measurable. Using the method, each need is given a score based on the following questions.
Needs with higher scores have higher priority in our community.
1) Measurable? Can we measure the outcome after we address this need? Assign a score
from 0 to 10.
Ability to Evaluate Outcomes Score
No ability to evaluate outcome 0
Perceptions only (anecdotal) 2
Perceptions + some data 4
Perceptions + data – surveys w/out ongoing evaluation 6
Perceptions + data – baseline data available for last yr 8
Perceptions + data – baseline data available for several years to 10

establish trends
2) Size? How much of the population does this health problem affect? Assign a score from 0 to
10.
Size of the Health Score
Problem
Less than 0.1% 0
0.1% to 0.09% 2
0.1% to 0.9% 4
1.0% to 9.9% 6
62
83
10% to 24.9% 8
25% or more 10
3) Seriousness? How serious is this problem as perceived by the community? Assign a score
from 0 to 10.
Seriousness of the Health Problem Score
No impact on community/county 0
Not serious, little impact on others 2
Moderately serious (illness, no general long term effect) 4
Serious – impacts others, increased hospitalization rates, some long term 6

effects
Relatively Serious – increased impacts on others, increased death rates, long 8

term effects on overall community/county
Very Serious – higher death rates, premature deaths, great impact on others 10
and overall community/county
4) Champion? Is there someone who will take personal responsibility for this issue? Add 1
point if yes, 0 points if no. (We have found that projects without dedicated, committed
“champions,” ideally more than one, tend to die on the vine without implementation. These
champions can be stakeholders or uninvolved community members -- as long as they have
some time to dedicate to speaking on behalf of the project and keeping it in mind.)
5) Concurrence? Does this issue meet a need that has been mentioned in multiple sectors by
multiple kinds of stakeholders? Add 1 point for each time this issue has been mentioned.
(Ie, is there broad consensus that there is a need for this project?)
6) Achievable? On a scale of 0 to 5, how achievable is this project? Assign a score from 0 to

5.
7) Useful? Does this solve a problem for one or more stakeholders? 1 point if yes, 0 points if
no.
8) Buy-in? Is there buy-in from one or more institutions? 1 point if yes, 0 points if no.
9) Innovative? Does this project do something unique and innovative? 1 point if yes, 0 points
if no.
84
Sample Prioritization Assessment:
Priority Score: 59
Measurable (0, 2, 4, 6, 8, 10): 10
Size (0, 2, 4, 6, 8, 10): 10
Seriousness (0, 2, 4, 6, 8, 10): 10
Champion (0 or 1) 1
Concurrence (# of stakeholders who want) 20
Achievable (0 or 1) 5
Useful (0 or 1) 1
Buy-in (0 or 1) 1
Innovative (0 or 1) 1
85
Appendix E: Gaps and Opportunities Ranked by Priority
Our research has indicated a series of gaps and corresponding opportunities in prevention,
treatment and recovery of substance use problems in the Catskills. We have ranked these
needs and opportunities according to our priority setting strategy outlined on page 75.
Gap 1: Lack of communication and collaboration among stakeholders, service providers and
community members.
Reaching communities that are difficult to reach is one of our largest concerns. Particularly,
people who are difficult to find -- such as disconnected youth -- require creative strategies to
reach them where they are. We haven’t yet cracked the code that allows all consortium
members to feel included and clued in to various consortia happenings. Most members of our
consortium have cited barriers to communication and collaboration as their number one concern
when it comes to responding to the overdose crisis. There is no centralized place for events and
information about addiction in Delaware County, or in the Catskills region. This was the
Opportunity: Create a communications plan for the Catskills Addiction Coalition that
creates a feeling of buy-in and connection among consortium members and the larger
community. The Catskills Addiction Coalition has brought together a large number of disparate
sectors that don’t normally talk to each other. It can use these connections to foster
communication, research and sharing of learnings to educate our community and agree on facts
on the ground together. There is desire in our community to know what is happening and to
reach out and learn from each other. Explore digital (e-newsletters, Slack, Facebook groups,
shared Google Calendars) and old-fashioned (in-person meetings, potlucks, living-room
gatherings) methods of creating networks and keeping each other informed. We have
experimented with a variety of strategies, including far-flung meeting attendance, regular email
newsletters, casual conversations with the Project Director, physical presence at a variety of
events where conversations can happen, weekly phone check-ins, public media appearances,
and more. Develop ways to measure the impact of various communication strategies. The
Catskills Addiction Coalition, which is already connecting disparate silos of addiction information
in the region, can host this calendar with the help of partners recruited by the Delaware County
Drug Use Task Force.
Priority Score: 59
Measurable (0, 2, 4, 6, 8, 10): 10
Size (0, 2, 4, 6, 8, 10): 10
86
Seriousness (0, 2, 4, 6, 8, 10): 10
Champion (0 or 1) 1
Achievable (0 or 1) 5
Useful (0 or 1) 1
Buy-in (0 or 1) 1
Gap 2: No affordable public transportation in much of the region.

Delaware County is one of only two counties in New York State without public transportation,
and this lack of easy and affordable ways to get around disproportionately affects prevention,
treatment and recovery efforts in the region. From a prevention perspective, people have less
access to healthcare, recreation, and work; the lack of transportation creates huge barriers to
treatment, particularly for people who may have lost their licenses; and people in recovery are
limited from getting to their jobs, homes and support systems because of this issue.
Opportunity: Stakeholders in every sector are eager to create more and better forms of public
transportation in the Catskills, and such a system would likely be grant funded and would
consolidate redundant, costly resources. Leadership and persistence, as well as public
pressure, are key to making more transportation solutions to serve our focus populations.
Priority Score: 57
Measurable (0, 2, 4, 6, 8, 10): 10
Size (0, 2, 4, 6, 8, 10): 10
Seriousness (0, 2, 4, 6, 8, 10): 10
Champion (0 or 1) 1
Achievable (assign a score from 1 to 5) 3
Useful (0 or 1) 1
Buy-in (0 or 1) 1
87
Gap 3: Lack of focus on substance issues and youth, particularly “disconnected youth.”
no point during the months of meetings and conversations I’ve had has the topic of treating
youths who are using substances come up. Yet the majority of the people in recovery I have
spoken with began using substances in high school or younger. The prevention resources in the
Catskills focus almost entirely on in-school interventions, a focus that completely misses
“disconnected youth,” who are not affiliated with local schools. Middle school children especially
need activities, because they are too young for sports but too old for the CROP after-school
program. Many members of our consortium are particularly concerned with offering mental
health services to disconnected youth, but also youth engagement programs. The concept of a
youth mentoring program or community youth center came up more often than any other idea at
the 2019 Catskills Addiction Coalition summit.
disconnected youth, in the Catskills, by combining youth engagement projects like a
youth center or a mentoring program with substance use and mental health resources
such as counselors and certified recovery peer advocates. Use the Margaretville Hospital
School Mental Health Program, which offers mental health counseling services to the families of
children in the schools, as a base upon which to expand. Robbie Martin, who runs the program,
has noted the problem of “disconnected youth” for her program and wants to expand her
in-school offerings to reach community members who are not in school -- for example, by
supporting after-school activities that are open to all community members and caseworker
services for the families of children in the school. Middle-school aged tweens should be a
particular focus on this programming. New York City has done a considerable amount of policy
work on the topic of disconnected youth, and our consortium can benefit by studying policies
and programs that have worked and may be transferable to a rural region.63
Priority Score: 56
Measurable (0, 2, 4, 6, 8, 10): 10
Size (0, 2, 4, 6, 8, 10): 10
Seriousness (0, 2, 4, 6, 8, 10): 10
Champion (0 or 1) 1
63
88
Useful (0 or 1) 1
Buy-in (0 or 1) 1
Gap 4: Low number of qualified workers in Catskills region; high number of people in recovery
who need work.
Opportunity: Several programs in the Catskills are addressing the fact that there is a lack of
qualified workers in Catskills region and a high number of people in recovery who need work.
These “recovery-friendly businesses” initiatives have been started by Friends of Recovery
Delaware Otsego and the Mountaintop Care Coalition. They work with people in recovery,
pairing them with businesses that need workers. A certified recovery peer advocate supports
both the employee and the employer. In the summer of 2019, the Catskills Addiction Coalition
and the Central Catskills Chamber of Commerce co-hosted a Recovery Friendly Businesses
breakfast that recruited local business owners to employ people in recovery. The Mountaintop
Cares Coalition is working with county labor officials on a similar program, and is collaborating
with the Catskills Addiction Coalition on the program. These programs need paid staff and
resources to thrive.
Priority Score: 49
Measurable (0, 2, 4, 6, 8, 10): 8
Size (0, 2, 4, 6, 8, 10): 4
Seriousness (0, 2, 4, 6, 8, 10): 8
Champion (0 or 1) 1
Useful (0 or 1) 1
Buy-in (0 or 1) 1
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Gap 5: The community needs a resource to go for drug use referrals, ideally with the word
“opioid” or “drug use” in the title.
Without advertising, our office has begun receiving calls from people who want general
information and referral services about addiction and substance use issues. Since September
2019, we have received five such calls, including a referral from a local provider, a woman who
had been discharged from Schoharie County and needed help; a call from hospital employee
who had a friend with a child with a substance use disorder; a call from the stepmother of that
same person, and a call from a woman who was leaving inpatient drug rehab and who needed a
referral. Margaretville Hospital has received more inquiries that have not made it to our desk:
nurses who staff the nursing station after-hours say that they regularly receive after-hours calls
from people inquiring about opioid services and referrals and have no place to send them, and
Stacy Wright, the office coordinator at the physical medicine and rehab office, says that she,
too, gets unsolicited calls about addiction, simply because the word “rehab” is in her office’s
name. Our naloxone trainer from OASAS told us that overdose survivors sometimes call their
local hospital or emergency room for information about recovery and lists of resources and
detoxes. Margaretville Hospital currently does not have resources to respond to such inquiries.
Opportunity: Establishing a regional help line for drug use referrals that can be accessed by a
range of hospitals, social service organizations and law enforcement professionals. Drug use
hotlines and help lines already exist in Ulster and Sullivan counties. Ulster County created such
a hotline in December 2019 by creating a voicemail located in the Sheriff's Office dispatch office
that emails a team of police officers when it gets a call, according to Sergeant Chad Storey at
the Ulster County Sheriff's Office. They plan on training several dispatchers to answer the
hotline live in the future, but for now they've spun it up this way. Sullivan County also operates a
drug use hotline that provides referrals. There is interest from several stakeholders in Delaware
County for establishing one here.
Priority Score: 44
Measurable (0, 2, 4, 6, 8, 10): 10
Size (0, 2, 4, 6, 8, 10): 6
Seriousness (0, 2, 4, 6, 8, 10): 10
Champion (0 or 1) 1
Useful (0 or 1) 1
Buy-in (0 or 1) 1
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Gap 6: Stigma causes resistance to adopting harm reduction programming.

The Catskills’ community’s cultural approach to and perceptions of addiction and recovery
cause a tremendous amount of resistance to creating, adopting and sustaining programs that
can help people people who use drugs and people in recovery. Cultural and institutional
resistance to a harm reduction approach to reducing morbidity and mortality from substance use
is rampant, subtle and powerful. This makes it difficult to implement overdose response
strategies even with time, money and resources available. Cynthia Heaney, the Delaware
County Director of Community and Mental Hygiene, says that stigma about substance use and
mental health has been a pervasive and confounding problem for her work. “When I first came
on board, I said, ‘We’ve got to do something with stigma reduction,’” she says. Heaney has run
a small pilot project funded by a SAMHSA grant to hire Jessica Vecchione, a local filmmaker, to
produce a series of videos and accompanying forums featuring people in recovery to combat
stigma, but the funding for that project has run out.
Opportunity: Cultural education/stigma are a huge opportunity in the Catskills. More funding
can be put into Jessica Vecchione’s existing homegrown education and outreach projects. That
work has already been approved by the Delaware County Board of Supervisors, the county’s
conservative governing body. This is a tremendous amount of buy-in in a conservative rural
county. The consortium could then use this anti-stigma storytelling content to partner with local
community resources like food pantries, schools and gyms, which would become conduits for
education for the general public and platforms to build trust with people who use substances.
Priority Score: 43
Measurable (0, 2, 4, 6, 8, 10): 4
Size (0, 2, 4, 6, 8, 10): 10
Seriousness (0, 2, 4, 6, 8, 10): 10
Champion (0 or 1) 1
Useful (0 or 1) 1
Buy-in (0 or 1) 1
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Gap 7: Certified recovery peer advocates (CRPAs) are not available easily and accessibly
throughout the region.
Delaware-Otsego (FOR-DO) is hoping to staff peers at Margaretville Hospital, but bureaucratic
barriers to these partnerships such as review by legal departments and funding must be
overcome first. It is particularly notable that the Delaware County Drug Court lacks a
recovery-based model of care, isn’t integrated into the healthcare system, and doesn’t
collaborate with FOR-DO, the local recovery organization, to have a peer support its
participants.
Opportunity: Explore flexible funding and collaboration models with peer agencies. Work
with Samadhi and FOR-Do to staff peers in accessible locations or have them respond in an
“on-call” manner when needs arise, in partnership with local emergency departments, private
businesses and police departments. This is an opportunity to explore flexible funding and
collaboration models with peer agencies. We would like to work with Samadhi and FOR-DO to
staff peers in accessible locations or have them respond in an “on-call” manner when needs
arise, in partnership with local emergency departments, hospitals, private businesses, police
departments. It is also worth considering obtaining funding and education for local drug
treatment courts to use peer services.
Priority Score: 42
Measurable (0, 2, 4, 6, 8, 10): 10
Size (0, 2, 4, 6, 8, 10): 6
Seriousness (0, 2, 4, 6, 8, 10): 8
Champion (0 or 1) 1
Useful (0 or 1) 1
Buy-in (0 or 1) 1
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Gap 8: Local mental health care services don’t necessarily address substance use.
The Margaretville Hospital School Mental Health program doesn’t explicitly offer substance use
The school mental health is popular and is receiving requests from other school districts to
expand, but its staff are too busy to grow the program without outside help. But its staff
acknowledge that substance use issues are appearing in the lives of the children they work with.
Opportunity: We can leverage mental health and substance use resources to complement
each other and collaborate. With funding for more counselors who can focus on substance use
in children and families, the school mental health program could be expanded to include
substance use treatment. With additional personnel, the school mental health program could
expand into substance use treatment and casework support for families and prevention
activities for the community. A grant could pay for an external evaluator to assess the program
and show the impact it is having on kids. We could collaborate with other area mental health
resources, including the Delaware County Mental Health Clinic and Rehabilitation Support
Services, Inc., both of which offer services for mental health and substance use issues. Perhaps
a combined substance use and mental health peer could work in the school system. We can
leverage mental health and substance use resources to complement each other and
collaborate. We could encourage combined mental health and substance use approaches to
community care with innovative job descriptions, shared work and combined training.
Priority Score: 40
Measurable (0, 2, 4, 6, 8, 10): 10
Size (0, 2, 4, 6, 8, 10): 8
Seriousness (0, 2, 4, 6, 8, 10): 10
Champion (0 or 1) 0
Useful (0 or 1) 1
Buy-in (0 or 1) 1
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Gap 9: No transitional affordable housing with adjacent accessible transportation available for
people in early recovery.
us during a focus group session in the fall of 2019 about the needs of people in recovery the
housing was a large issue for that population. “There are very few places people can live,”
Armanno said. She pointed out that the homeless shelter in Delaware County can only house
people for less than 30 days. Therefore, there is a need for affordable transitional housing with
adjacent accessible transportation for use by people in early recovery throughout the Catskills
region. Housing was the third highest priority need for improving overall health in the region
chosen by the Delaware County Long Term Care Council during its Mapping and Intercepts
Planning Exercise in July 2019, and was one of the priorities of focus chosen by participants in
the Catskills Addiction Coalition Summit Mapping Exercise from January 2019.
Opportunity: Josh Weaver, a person in recovery who volunteers with our coalition, researched
various recovery housing options in the Catskills, including a church in Fleischmanns and
various halfway houses, and has explored some potential funding options for such work.
Priority Score: 38
Measurable (0, 2, 4, 6, 8, 10): 6
Size (0, 2, 4, 6, 8, 10): 4
Seriousness (0, 2, 4, 6, 8, 10): 8
Champion (0 or 1) 1
Useful (0 or 1) 1
Buy-in (0 or 1) 1
Gap 10: Cultural divides and a lack of understanding of conditions on the ground has tied up
$150,000 in opioid funding.
According to Robert Kent, the general counsel for the New York State Office of Addiction
Services and Supports (OASAS), while Delaware County is eligible to access up to $400,000 in
State Opioid Response (SOR) funding, the county has not accessed those funds.
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When I spoke with Cynthia Heaney, the Delaware County Director of Community and
Mental Hygiene, whose office is the gatekeeper for at least some of these funds, she told me
that OASAS is not recognizing rural realities on the ground that prevent the county from easily
using these funds.
Her department was offered $150,000 in State Opioid Response (SOR) funding earlier in
2019 to hire Certified Recovery Peer Advocates (CRPAs), purchase vehicles and telemedicine
equipment, to provide transportation for patients to OUD disorder and to attract and pay for
waivered buprenorphine providers. She declined to accept the funds because she was unable
to use them for multiple reasons, she says:
● The short time frame. The money had to be spent by September 30, 2019, while her
budget planning for adding new positions to her agency must be done a year in
advance.
● Peers (CPRAs) could only be hired directly, not contracted. The funds could not be used
to contract with peers from an existing peer agency, Friends of Recovery, because
restrictions on the funding only allow for the peers to be hired directly by the agencies so
that their services can be billed to Medicaid.
● Concerns about cost, ongoing funding and liability for the county.
● General rigidity of the parameters of the funding, which don’t recognize rural needs. “The
reality is that I don’t think the best place for a peer is as a county employee in a
brick-and-mortar clinic,” she says. “We’re not flexible. We work 9 to 5 Monday through
Friday, and people that need help in addiction need help at additional times. You need
peers who have the flexibility to go to the emergency room; you need peers who have
the flexibility to go where folks are.”
● Compounding the problem is that Delaware County has been shamed publicly for its
concerns about spending this money, Heaney says.
Opportunity: Change requirements on spending State Opioid Response funds to allow

rural counties like Delaware more flexibility. With help, more active listening and more
sensitivity to unique rural and cultural needs, our consortium could overcome the barriers to
using SOR funding and perhaps other funding as well. A dedicated group of people who could
consult with the state and provide support to the county and local agencies would go a long way
towards smoothing the way for collaboration.
Priority Score: 37
Measurable (0, 2, 4, 6, 8, 10): 10
Size (0, 2, 4, 6, 8, 10): 8
Seriousness (0, 2, 4, 6, 8, 10): 6
Champion (0 or 1) 1
95
Useful (0 or 1) 1
Buy-in (0 or 1) 1
Gap 11: Local police are the first point of contact with people with substance use problems, and
yet have little understanding of addiction and no referral mechanism to connect people who use
drugs with treatment and recovery resources.
In the Catskills, the police are the main point of contact between the government and people
who use drugs or who are in need of medical services because of overdose. There is a great
deal of fear among police for dealing with “dangerous” situations when responding to drug use
calls. At our focus group with Catskills sheriff and state police representatives, multiple officers
spoke of the need for more safety resources for police when encountering people who use
drugs. There was also a negative perception of medication assisted treatment: the head of
Delaware County’s probation office, an investigator with the New York State Police, the head of
the county’s homeless shelter and the Delaware County Sheriff all expressed skepticism about
the efficacy of buprenorphine for managing substance use disorder, saying that they had heard
anecdotally that buprenorphine didn’t work.
This fear and lack of understanding can create tension in emergency situations involving
substance use. Nelson Delameter, the Margaretville Fire Department Chief, says that often the
New York State Troopers on a scene will aggravate overdose survivors and make the situation
more volatile.
The police’s role as the first point of contact can also interfere with getting people
connected to health resources. In the fall of 2019, there was an incident at Margaretville
Hospital where an agitated person who was suspected to have some kind of substance use
issue did not make it into the hospital. Instead, the police arrived and took this person to a
destination outside the region. I have heard multiple reports about this incident from folks in the
hospital but have been unable to substantiate it with data, despite investigating with the Quality
Assurance department, Security and the Head of Nursing.
Beginning in January 2020, a new bail reform law in New York will change the way the
police arrest and hold people. People who are encountered by the police in New York State will
no longer be held on bail for most offenses, including substance use offenses. Craig Dumond,
the Delaware County Sheriff, says that this means that services for people who use drugs will
suffer. “We will no longer have a captive audience,” he says. “They want us to do everything.
We are the default mental health agency.”
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Opportunity: Work with local police, hospitals, and social services providers to build a referral
service for police to direct people with substance use issues toward help. As the police find
themselves needing a new way to handle people who use drugs at the point of arrest, offer
them ways to refer those people to social services, following Law Enforcement Assisted
Diversion guidelines. Regional police agencies are interested in this approach, and some, like
Schoharie County and Ulster County, area already implementing them. Police and providers in
Sullivan County, Delaware County and Greene County are curious about this approach. This is
an opportunity to bring them together to learn from each other.
Priority Score: 37
Measurable (0, 2, 4, 6, 8, 10): 10
Size (0, 2, 4, 6, 8, 10): 10
Seriousness (0, 2, 4, 6, 8, 10): 10
Champion (0 or 1) 1
Useful (0 or 1) 1
Buy-in (0 or 1) 0
Gap 12: Not enough findable, accessible and affordable MAT providers in region.
There are no OASAS-certified clinics offering a full range of medication assisted treatment in the
Catskills region. The Delaware County Alcohol and Drug Abuse clinic offers only naltrexone
(Vivitrol), but no buprenorphine or methadone. No Catskills emergency rooms offer
buprenorphine induction, and there are only ten buprenorphine providers in the region, some of
which are private pay and do not take Medicaid. An attempt in 2019 to offer buprenorphine
waiver training to Delaware County providers was unable to train any new area providers.
Opportunity: Establish MAT in area emergency departments
A Critical Access Hospital just south of the Catskills region, Ellenville Regional Hospital, is
successfully offering three-day buprenorphine induction in its emergency department. We can
follow their example (which is also the result of HRSA planning and implementation grants), to
offer more MAT in the Catskills region. The medical director of Margaretville Hospital’s
emergency department is on board, as is the hospital’s administrative staff. Our team has
ranked this strategy as the third most important and feasible evidence-based strategy we could
implement in the Catskills.
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Priority Score: 34
Measurable (0, 2, 4, 6, 8, 10): 10
Size (0, 2, 4, 6, 8, 10): 2
Seriousness (0, 2, 4, 6, 8, 10): 10
Champion (0 or 1) 1
Useful (0 or 1) 1
Buy-in (0 or 1) 1
Gap 13: Rural first responders and community members know little about naloxone and often
don’t carry it.
In our region, there is a lot of misinformation and misunderstanding about why and how
overdoses happen, and even what they are. Our experience hosting a naloxone training showed
that such trainings attract engaged community members who are interested in learning about
how to save lives via harm reduction principles. Our experience also showed that there is a
need for naloxone trainers who are first responders who are familiar with the needs of rural
areas. Also, fears about liability make it difficult for local first responders to adopt harm reduction
measures. Our team has ranked a targeted naloxone distribution strategy as the second most
important and feasible evidence-based strategy we could implement in the Catskills.
Opportunity: Targeted naloxone training and distribution aimed at rural first responders
using trained, culturally literate naloxone trainers.
Naloxone trainings have drawn interest from a range of participants in the Margaretville region,
and with coordination and organization could be spread throughout the region. Eight people
from a variety of local organizations attended a naloxone Training at Margaretville Hospital
December 3, 2019, and several have followed up to indicate that they would like trainings for
their own organizations. The OASAS trainer said that hospitals and individuals can become
Opioid Prevention Programs and can sign up to distribute naloxone for free, and that the only
OPP signed up in Delaware County is the Village of Delhi Police Department. This is an
opportunity to Margaretville Hospital and other consortium partners to distribute free naloxone in
the region, and to coordinate existing efforts for naloxone trainings. Kim Lacey, the
administrative assistant on our grant, has begun her training to become a naloxone trainer with
local rural cultural understanding. This is also an opportunity to address liability fears with
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information and research about, for example, why administering naloxone won’t harm your first
responders.
Priority Score: 32
Measurable (0, 2, 4, 6, 8, 10): 4
Size (0, 2, 4, 6, 8, 10): 4
Seriousness (0, 2, 4, 6, 8, 10): 10
Champion (0 or 1) 1
Useful (0 or 1) 1
Buy-in (0 or 1) 1
Gap 14: Little coordination between medication assisted treatment providers and services.
As hospitals, emergency departments, inpatient rehabilitation organizations, outpatient
medication assisted treatment providers and recovery organizations work to collaborate to
provide continuous, uninterrupted treatment services to people with opioid use disorder, a need
has emerged for the role of “care coordinators” who can bridge gaps between each of these
organizations. Doctor Wesley Ho, who works with providers prescribing outpatient medication
assisted treatment at the Institute for Family Health in Kingston, told us in November 2019 that
there is a great need for this kind of care coordinator role. Maya Hambright, a waivered
buprenorphine provider based in Woodstock, and Dr. Gigi Madore, the medical director of the
Kingston Hospital Emergency Department, tell us that people who visit emergency departments
sometimes require bridge prescriptions for buprenorphine, if they cannot be induced directly in
the emergency room directly. Hambright, working with the Samadhi recovery center in Kingston,
is exploring whether to provide those kinds of “bridge” prescriptions. As Ulster County works to
provide medication assisted treatment in its county jail, it is struggling to provide the
coordination of care that will connect people to their providers when they leave jail. We have
been surprised to observe that no one from the local substance use clinic or the local hospital
system is attending organizational meetings for the jail medication assisted treatment initiative in
Ulster County.
Opportunity: This is an opportunity for our consortium to bring local hospitals to the table and
to create care coordination positions and other “bridge” services, such as bridge buprenorphine
99
prescriptions, that will provide continuous care for people as enter and leave institutions return
to their lives in the community.
Priority Score: 32
Measurable (0, 2, 4, 6, 8, 10): 8
Size (0, 2, 4, 6, 8, 10): 4
Seriousness (0, 2, 4, 6, 8, 10): 8
Champion (0 or 1) 1
Useful (0 or 1) 1
Buy-in (0 or 1) 1
Gap 15: Re-entry into community life from incarceration is difficult for people in recovery.
Opportunity: A recovery re-entry group led by Paul Fontana in Delhi aims to offer regular
mutual aid meetings, subsidized gym passes, employment referrals, group exercise
opportunities, and trainings on re-entering life from incarceration to people in recovery.
Priority Score: 31
Measurable (0, 2, 4, 6, 8, 10): 4
Size (0, 2, 4, 6, 8, 10): 4
Seriousness (0, 2, 4, 6, 8, 10): 10
Champion (0 or 1) 1
Useful (0 or 1) 1
Buy-in (0 or 1) 1
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Gap 16: Many patrons at the local food pantry have problems stemming from substance use.
According to the founder of the Community Pantry in Margaretville, the pantry, which serves
500 families locally, has noticed that many of its patrons have problems stemming from
substance use.
Opportunity: This could become an opportunity to use the food pantry, which serves 500
people locally, as a conduit for education and a source of connection to build trust with various
people who use substances. We could host a naloxone training there or host mutual aid
meetings there, for example.
Priority Score: 27
Measurable (0, 2, 4, 6, 8, 10): 2
Size (0, 2, 4, 6, 8, 10): 6
Seriousness (0, 2, 4, 6, 8, 10): 8
Champion (0 or 1) 1
Useful (0 or 1) 1
Buy-in (0 or 1) 1
Gap 17: Pharmacists are hesitant to and/or stymied from using harm reduction strategies.
Only twelve pharmacies in the Catskills region have standing orders to distribute naloxone,
according to the Statewide Directory arranged by County.64 Despite the fact that state law
requires that pharmacies take back unused opioids, the local CVS pharmacy in Margaretville
does not participate. Cindy Cullen, the pharmacist in Margaretville, says that “it’s very
dangerous because it’s like handing cash over to somebody. I can’t take it, I can’t personally put
my hands on it.” The Margaretville Hospital Community Pharmacy isn’t set up for the free
naloxone distribution program because of past institutional resistance.
64
https://www.health.ny.gov/diseases/aids/general/opioid_overdose_prevention/docs/pharmacy_
directory.pdf.
101
Opportunity: Train and recruit pharmacists to provide holistic prevention, treatment and
recovery care. Local pharmacists are interested in providing holistic prevention, treatment and
recovery care to people with opioid use disorder. A pharmacist in Tannersville in Greene County
is spearheading a pharmacy wellness initiative that could be replicable throughout the region,
which staffs pharmacies with “wellness coordinators.” This is an opportunity to Include
pharmacists in community coalitions to assess their concerns about danger and give them a
sense of community support for harm reduction strategies.
Priority Score: 27
Measurable (0, 2, 4, 6, 8, 10): 6
Size (0, 2, 4, 6, 8, 10): 6
Seriousness (0, 2, 4, 6, 8, 10): 2
Champion (0 or 1) 1
Useful (0 or 1) 1
Buy-in (0 or 1) 1
Gap 18: There is unused capacity at Margaretville Hospital.

Opportunity: A local substance use clinic could fill that empty space and simultaneously create
outpatient substance use care where there isn’t any in the center of the Catskills. Getting a New
York State certified substance use clinic requires a fair amount of bureaucratic labor, however.
Priority Score: 25
Measurable (0, 2, 4, 6, 8, 10): 10
Size (0, 2, 4, 6, 8, 10): 4
Seriousness (0, 2, 4, 6, 8, 10): 6
Champion (0 or 1) 1
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Useful (0 or 1) 1
Buy-in (0 or 1) 1
Gap 19: Need for data and services geared towards those infants and towards pregnant people
with physical dependence on opioids or who have opioid use disorder.
Because the Catskills have a high rate of infants with neonatal opioid withdrawal syndrome
(NOWS), data is needed to track whether pregnant people in the Catskills are using medication
assisted treatment, which is an appropriate way to treat pregnant people with opioid use
disorder, or if they are using illicitly manufactured fentanyl or heroin or diverted prescription
opioids, which puts them at risk. Pregnant people with physical dependence on opioids or who
have opioid use disorder need access to buprenorphine, and maternity and neonatal services
that understand and support medication assisted treatment as the most efficacious way to
manage substance use disorders. Infants with NOWS need targeted services at home in the
Catskills once they are discharged from maternity hospitals outside the region.
Opportunity: Education for and collaboration between medical providers and hospitals about
pregnancy and opioid use disorder could help steer more pregnant people with opioid
dependence issues or active opioid use disorders to medication assisted treatment, reducing
their potential use of diverted prescription and pharmacotherapy or illicitly manufactured fentanyl
or heroin. We could reach out to health officials Sullivan County and in Rhode Island to learn
about best practices for supporting birthing parents who are on medication assisted treatment,
neonatal withdrawal procedures and protocols, the cost savings of recovery programs, the
benefits of remaining connected to the mother, and the usefulness of peer educators who are
also mothers who have substance exposed newborns. Margaretville Hospital is introducing
several new OB-GYN providers to the Catskills region, and another, Denine Polen, has set up
an independent practice on her own. These folks can be educated about medication assisted
treatment. Perhaps Margaretville Hospital can also introduce some kind of outpatient parent
advisory program to help parents navigate neonatal withdrawal syndrome locally and in
partnership with out-of-county neonatal care units.
Priority Score: 23
Measurable (0, 2, 4, 6, 8, 10): 10
Size (0, 2, 4, 6, 8, 10): 2
Seriousness (0, 2, 4, 6, 8, 10): 6
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Champion (0 or 1) 0
Useful (0 or 1) 1
Buy-in (0 or 1) 0
Gap 20: Lack of information about treatment options in the Catskills.

The presence of an OASAS drug and alcohol clinic in the county is barely publicized and
little-discussed. It took us months before we even knew where the clinic was located.
Furthermore, the patchwork of halfway houses, ad hoc rehabilitation facilities and private
programs is confusing and is not centrally organized. Indeed, area rehab facilities are beginning
to call our project to ask if they can get the word out through our office about the fact that they
exist. There is no way for us to independent vet these programs for safety, trustworthiness or to
track their results.
Opportunity: Participation in the Shatterproof ATLAS “Yelp for Rehab” project65 and help
county and local resources participate in the program. Also, provide information sharing by the
CAC and new staff. The Delaware County clinic has a new director who attends task force
meetings and may be interested in collaborating.
Priority Score: 21
Measurable (0, 2, 4, 6, 8, 10): 4
Size (0, 2, 4, 6, 8, 10): 4
Seriousness (0, 2, 4, 6, 8, 10): 10
Champion (0 or 1) 0
Useful (0 or 1) 1
Buy-in (0 or 1) 0
65
https://www.shatterproof.org/atlas
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Gap 21: Few pain management resources.

Several of our informants in the healthcare industry cited a lack of proper pain management
care as a driver of opioid use in our region. The manager of a local clinic said that one of her top
needs is access to “referral plans for pain management” for her patients.
Opportunity: Find and connect pain management programs and refer patients to such
programs. Look at Ellenville Regional Medical Center for an example of collaborate pain
management practices, and perhaps bring representatives from Ellenville to Margaretville
Hospital.
Priority Score: 21
Measurable (0, 2, 4, 6, 8, 10): 4
Size (0, 2, 4, 6, 8, 10): 4
Seriousness (0, 2, 4, 6, 8, 10): 2
Champion (0 or 1) 1
Useful (0 or 1) 1
Buy-in (0 or 1) 1
Gap 22: There is a lack of harm reduction resources in the Catskills.

Opportunity: Work with stakeholders to create more prescription take-back boxes, community
sharps collection sites, HIV/Hep C testing centers, syringe exchanges and Opioid Prevention
Programs (OPP) that distribute naloxone.
Priority Score: 19
Measurable (0, 2, 4, 6, 8, 10): 10
Size (0, 2, 4, 6, 8, 10): 4
105
Seriousness (0, 2, 4, 6, 8, 10): 0
Champion (0 or 1) 0
Useful (0 or 1) 1
Buy-in (0 or 1) 0
Gap 23: Data about substance use, drug markets and overdose is difficult to get.
Before assessing existing efforts for prevention, treatment and recovery in the Catskills, it is
necessary to assess the quality of data available to measure such systems as well as
prevalence of and demand for opioid use disorder services. It turns out that even gathering
accurate data about the prevention, treatment and recovery services that are are available is
difficult, due to siloing of information, incompatibility of different data sources, barriers between
agencies and groups and counties, and a sense of “it’s not my job.” Amanda Walsh and Kali
Delmar at Delaware County Public Health tell us that getting data from police and hospitals for
creating overdose maps has been a challenge. The Catskills region is large and there appears
to be variation throughout the region in which drugs are used where and what kinds of drugs
cause overdoses. For example, our informants in Delaware County tell us anecdotally that
opioid use is falling and methamphetamine use is rising in Delaware County, while fentanyl
overdoses have become more widespread in Ulster County in the fall of 2019.
Opportunity: Provide more money and manpower to staff data gathering efforts. Talk to key
interviews with people who use drugs and those who serve them in regional markets to gain a
better sense of how the landscape operates. Our response to substance use in the region can
be tailored to different conditions in different parts of the Catskills.
Priority Score: 19
Measurable (0, 2, 4, 6, 8, 10): 10
Size (0, 2, 4, 6, 8, 10): 4
Seriousness (0, 2, 4, 6, 8, 10): 0
Champion (0 or 1) 1
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Useful (0 or 1) 0
Buy-in (0 or 1) 0
Gap 24: No coordinated way to screen for and respond to drug use in local emergency rooms.
At Margaretville Hospital, staff members tell us that there is no way to screen for substance use
in the current emergency department workflow. This is an opportunity to introduce the SBIRT
substance use screening tool to the emergency department. Emily Taggart, the social worker at
neighboring O’Connor Hospital, tells us that she manually looks through emergency department
records to find substance use patients, whom she then refers to a certified recovery peer
advocate from Friends of Recovery Delaware Otsego who comes to the emergency department
in person.
Opportunity: Educate emergency department staff and reframe area emergency department
missions to include substance use help. Protocols to include the Screening, Brief Intervention,
and Referral to Treatment (SBIRT) and Brief Negotiated Interview tools in emergency
department protocols, training of staff, and convincing of hospital bureaucracy would be
necessary to change the culture of Catskills emergency departments into welcoming places for
people with addictions to seek help. We can offer resources and trainings to introduce those
tools to area hospitals.
Priority Score: 19
Measurable (0, 2, 4, 6, 8, 10): 6
Size (0, 2, 4, 6, 8, 10): 6
Seriousness (0, 2, 4, 6, 8, 10): 2
Champion (0 or 1) 0
Useful (0 or 1) 1
Buy-in (0 or 1) 0
107
Gap 25: Risk of overdose is especially high when a person is discharged from treatment or jail.
According to the New York State OASAS trainer who conducted our naloxone training, issuing a
naloxone kit to everyone leaving rehab or jail would prevent overdose, because people are at
particularly high risk of overdosing when they return home from such institutions.
Opportunity: Create a targeted campaign to distribute naloxone to people leaving jails and
rehab and returning to the Catskills region, and to their families. There may be may be New
York State Delivery System Reform Incentive Payment (DSRIP) Medicaid funding for
“transitional care” that could fund this program. This program could coordinate with community
jail re-entry programs.
Priority Score: 17
Measurable (0, 2, 4, 6, 8, 10): 2
Size (0, 2, 4, 6, 8, 10): 4
Seriousness (0, 2, 4, 6, 8, 10): 4
Champion (0 or 1) 1
Useful (0 or 1) 0
Buy-in (0 or 1) 0
108

Needs Assessment - Catskills Addiction Coalition

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Needs Assessment - Catskills Addiction Coalition

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Needs Assessment and Priority Setting

Rural Communities Opioid Response Program

Grantee Organization: Margaretville Hospital/WMC Health Network

Project Director: Julia C. Reischel

Contributing Consortium Members and Stakeholders:

A. Introduction / Background Information 10

B. Vision / Mission / Planning Values 14

C. Needs Assessment Methodologies 14

D. Overview of Results / Findings 15

E. Discussion / Conclusion: Gaps and Constraints / Assets and Opportunities 56

Appendix A: Needs Assessment Methodologies 62

Appendix B: Living in Recovery Survey 69

Appendix C: Catskills Addiction Coalition Community Action Plan 78

Appendix D: Prioritization Strategy 85

Appendix E: Gaps and Opportunities Ranked by Priority 88

We value transparency, connection, collaboration, warmth, relationships, healing, data-informed

The Catskills Addiction Coalition is focusing on the following target populations:

● Evidence-based treatment strategies such as medication assisted treatment with

Priority Needs and Issues

1. Coordination and communication: Media, outreach, connection

Rate of fatal overdose deaths per 100,000 population13

B. ​Vision / Mission / Planning Values

C. ​Needs Assessment Methodologies

D. ​Overview of Results / Findings

Opportunities: Focus prevention, treatment and recovery services on youth, particularly

2. All area youth

Opportunities: Focus prevention, treatment and recovery services on youth, particularly

4. ​People who use drugs and other substances in general

Opioid overdose death data

Rate of fatal overdose deaths per 100,000 population27

The role of fentanyl in fatal overdoses in the Catskills

“Because it is not possible to distinguish illicit fentanyl from medically administered

4. People who consider themselves in recovery from substance use

Qualitative Data: As we have conducted our research through conversations, interviews,

b. Findings for service systems

Overdose Prevention: Police response and naloxone distribution and training

Medication Assisted Treatment in the Catskills

The information in the SAMHSA buprenorphine provider database is erroneous, however: We

Counseling, Care Coordination and Certified Recovery Peer Advocates (CRPAs)

As hospitals, emergency departments, inpatient rehabilitation organizations, outpatient

An interesting and innovative approach to treatment is to collaborate with pharmacists, some of

Samadhi Recovery Community Outreach Center in Kingston is a newly-opened recovery center

National and Federal

New York State

● Friends of Recovery Delaware-Otsego.

c. Findings for workforce

2. Areas of workforce shortage and gaps in workforce

Psychiatrists 5 3 very few available in upstate NY, especially child

LCSW positions 5 2 No available workers are applying for vacancy

Licensed Mental Health 5 5 No available workers are applying for vacancy

3. Necessary competencies to provide OUD services

5. Evidence-based practice areas

6. Necessary capacity building

7. Resources that can support ongoing workforce development

● National Health Service Corps (NHSC) Loan Repayment Program

d.​ ​Priority setting strategy

11. Coordination and communication: Media, outreach, connection

• Acceptability: Will the community accept working on this issue? Is it wanted?

E. Discussion / Conclusion: Gaps and Constraints / Assets and

Opportunities:​ ​Focus prevention, treatment and recovery services on youth, particularly

Opportunity: Change requirements on spending State Opioid Response funds to allow

2019 Catskills Addiction Coalition Summit Mapping Exercise

Top issues chosen by the group:

B. Vision / Mission / Planning Values

C. Needs Assessment Methodologies

D. Overview of Results / Findings

4. People who use drugs and other substances in general

d. Priority setting strategy

Opportunities: Focus prevention, treatment and recovery services on youth, particularly

6) Achievable? On a scale of 0 to 5, how achievable is this project? Assign a score from 0 to