In late June, the state’s commissioner for addiction services, Chinazo Cunningham, stood in front of a packed ballroom of care providers. There was a map of New York on a projector screen, covered in blue splotches. Those blobs, she assured the room, would help get methadone to people in treatment for opioid addiction.

Each blob was supposed to show a two-hour driving radius for the state’s new fleet of mobile medication units — effectively methadone clinics on wheels, operated by healthcare contractors. On paper, it’s a simple proposal: Bring the medication to patients who can’t get it. The state would fund up to 35 units, Cunningham told the room, eliminating a vast treatment desert that spans most of the state.

The commissioner was optimistic. So was her boss. In her State of the State book, Hochul touted “several” vans that had hit the streets, delivering the medication to New Yorkers who struggled to get access.

But those 35 vans wouldn’t materialize. In reality, 11 were planned. And two years after the state proposed them, only two are in operation — both in New York City.

Upstate New Yorkers are more likely to die from an opioid overdose than people living in the city. They’re admitted to emergency departments for overdoses 31% more often per capita than people in the five boroughs, and they’re prescribed opioids more than twice as often.

Although it’s one of the oldest, methadone remains often the best treatment option for patients with severe addictions — and it has become increasingly necessary as the drug supply has become both more addictive and more lethal. While the state’s plan lags, more and more New Yorkers have struggled to get one of the gold standards for opioid treatment.

A New York Focus analysis of treatment data from the state’s Office of Addiction Services and Supports found that methadone is incredibly difficult to access in most of the state. In huge swaths of upstate New York, it’s almost entirely unavailable.

New York Focus found:

¯ The average New Yorker has to travel at least 9.6 miles to reach the nearest clinic offering methadone on site. When New York City is excluded, the distance is 15.1 miles.

¯ That distance is growing every year. Since 2018, the average distance traveled has increased by more than three and a half miles — a 60% hike over five years.

¯ Even as overdoses spike, fewer people than ever are getting access to treatment in New York. Admissions to opioid treatment programs were at their peak in 2007, at 14,326. By 2021, the latest year for which data is available, that number declined to 11,609 — a 19% drop, and a close second to the lowest number in 14 years.

¯ Just 34 of New York’s 62 counties have an opioid treatment program site.

¯ The vast majority of opioid treatment capacity — 68% — is concentrated in New York City, even though 57% of New York state residents live outside the five boroughs. Although the city covers just over half a percent of the state’s total land area, it accounts for more than half of all locations that offer methadone on site.

¯ As a result, people outside the city have to travel nearly three times further on average to reach an opioid treatment program.

Experts reviewing New York Focus’s findings expressed dismay about the significance of the disparity.

“It becomes an issue of privilege and access the minute that you see a map like this,” said Megan French-Marcelin, senior director for New York State policy at Legal Action Center.

For many people who live upstate, the distances can be crushing. They don’t have the same robust public transportation system as patients in New York City, and they often don’t have a car. This can make the average nine and a half miles virtually impossible to cover — and at least 1,150 people admitted to treatment programs had to travel twice that distance to reach a treatment program. If they’re lucky, they might have a bus that will take them near the clinic or be able to take a cab paid for by Medicaid, but the commutes can still take hours out of their daily lives.

In many cases, experts have pushed buprenorphine as a solution in rural areas. It isn’t as strictly regulated, and it’s well-suited to combat heroin addiction. But with fentanyl in circulation, more physicians are realizing that buprenorphine isn’t a one-size-fits-all solution. Some clinicians have suggested that current dosing guidelines for buprenorphine aren’t sufficient to control cravings for the more potent synthetic opioid. And in some cases, people on buprenorphine run a higher risk of going into severe withdrawal than those taking methadone.

Methadone, French-Marcelin said, “is a solution that’s readily available, scientifically tested, and considered a gold standard of medication.” But the state is “not enabling people to use that in a safe and effective way.”

In a statement to New York Focus, OASAS spokesperson Evan Frost wrote that “Medication for addiction treatment, including methadone, has been proven to be safe and effective, and reduce overdose deaths by as much as 50%. OASAS continues to work closely with our providers to increase access to this medication across the state.”

Frost could not provide more information when asked about the discrepancy between Cunningham’s public remarks and the state’s plans.

According to the vision Cunningham presented last summer, the vans will help patients by eliminating at least some of their daily commute. But a hypothetically simple task — outfitting a cargo van with a locking refrigerator and delivering medication — is massively complicated by a tangle of state and federal regulations.

“It’s not a mystery,” said Dr. Noa Krawczyk, a professor of population health at New York University’s Grossman School of Medicine, “We know very well why there’s gaps in these areas.” In her view, federal policies on methadone distribution are the largest impediments to access in rural areas like upstate New York.

From 2007 to 2021, the federal Drug Enforcement Agency maintained a moratorium on mobile units, citing concerns about safety and medication diversion. When pandemic-era restrictions put many methadone clinics out of reach, the DEA announced a rule change to allow new mobile units. A few months later, OASAS issued a request for proposals for providers to begin rolling out the vans, hopeful that they would be able to bridge the gaps in methadone access.

There was a major catch. Under federal rules, the vans can only be run by preexisting brick-and-mortar opioid treatment programs — which are rare in upstate New York.

Opioid treatment programs are difficult to start in rural areas. Providers have to recruit trained staff, develop a large enough client base to be financially viable, and potentially defeat local opposition. As a result, some rural counties with high overdose death rates also have disproportionately little capacity in treatment programs. New York City, where the two operational methadone vans are located, does not have these problems for the most part (though some local advocates have pushed to reduce the number of methadone programs in Harlem).

To get the client bases they need, some of the methadone vans will likely target population-dense areas instead of the hard-to-reach corners of the state that Cunningham pointed to during her presentation. One of the first upstate methadone vans is expected to hit the road in March. Run by Cayuga Addiction Recovery Services, it will travel from their facility in Ithaca to Norwich with two stops: the county jail, and a parking lot in the latter city.

“I think it was a smart choice for that program to kind of figure out where people need the access here in our community,” said Allegra Schorr, President of the Coalition of Medication-Assisted Treatment Providers and Advocates of New York State. “I don’t know that they have a plan to go much further away.”

Even if the economics work out, the rat’s nest of paperwork, bureaucracy, and inspections can set back the rollout for a new van by months. VIP Services, which operates one of the two city-based vans, reported that its unit was sitting, waiting to be used, from July to November.

Pressure is mounting on Hochul to expand treatment upstate and to get overdoses under control. As the governor pushes her priorities for the state budget, observers will be looking for new tactics to connect people with medication-assisted treatment — and for any evidence that the mobile medication units are being rolled out.

“We’ve all seen lives in every corner of the state sapped by opioid dependence,” Hochul said during her State of the State address, promising to expand access to naloxone and fentanyl test strips. She made no mention of methadone or other medication-assisted treatments.

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This story originally appeared in New York Focus, a non-profit news publication investigating how power works in New York state. Sign up for their newsletter at https://tinyurl.com/368trn9p.