In the evolving public discourse responding to COVID-19, people who use drugs (PWUD) have been almost universally omitted. This is not a surprise—but it is a mistake. According to drugwarfacts.org, PWUD make up approximately 20% of the population. They are your store clerks, bartenders, physicians, lawyers, family, and friends—all of whom continue to be left out of health policy initiatives. Particularly ignored are PWUD with multiple marginalized statuses and experiences related to class, race, incarceration, poverty, documentation status, trauma, disability, gender, sexuality, and more. Discrimination and stigma act as major barriers to care and services, placing these individuals at increased risk of viral infections such as HIV and Hepatitis C (HCV), bacterial infections and now, infection with and transmission of COVID-19. Trystereo and other harm reduction groups throughout the world have long recognized the importance of centering the philosophy of harm reduction into public health, medicine, policy, and culture. The COVID-19 pandemic further illuminates the pressing need for this to happen.
Harm Reduction: A Quick Primer
Harm reduction is a philosophy—and a movement—which accepts the reality that people do use drugs and will continue to do so. Rather than moralizing, stigmatizing, or deploying punitive and ineffective strategies to address drug use (like the catastrophic and deadly War on Drugs), harm reduction seeks to minimize the risks associated with using drugs. Over the past three decades, the harm reduction movement has pushed forward policies and services such as syringe access programs (SAPs), overdose response measures, and safer consumption sites. SAPs are broadly accepted as essential to reducing HIV and HCV transmission. According to the CDC, they are “an effective component of comprehensive community-based prevention and intervention programs that provide additional services.” Harm reduction is not just a public health intervention—indeed, often the first entry point into health care for many PWUD—but also a social justice movement that compels us to rethink the hierarchical dynamics fracturing relationships between patient-clients and providers. This is important during “normal” times. During disaster events it is even more vital.
COVID-19 and Drug Users’ Health
Many drug users are at an increased risk of infection due to possible side effects of drug use (e.g. smoking and snorting drugs can inflame respiratory passages and may make people more susceptible to COVID-19 infection). Drug users are also at risk of worse outcomes from infection (such as an increased risk for opioid overdose, wherein breathing ceases, due to the respiratory target of this virus). Due to the social stigma of drug use that keeps many PWUD away from clinics, they also have higher rates of inadequately managed chronic medical conditions such as COPD, emphysema, high blood pressure, HIV, and diabetes. Based on the data that has been collected, there are higher rates of serious disease and death amongst people with chronic cardiovascular conditions, compared to those without.
Though the COVID-19 infection itself is an immediate concern, a prolonged and worsening pandemic will complicate public health efforts. Social distancing will limit the ability of harm reduction organizations such as Trystereo to provide safe injection supplies to participants. Most PWUD are not able to purchase syringes at pharmacies due to barriers such as cost, location, pharmacists’ discretion, and local requirements for identification or prescriptions. With health care providers overwhelmed by COVID-19 cases, the limited accessibility of other health services during this time may exacerbate already existing medical issues. Reusing needles will cause increased cases of skin infections (abscesses, cellulitis), bloodstream infections, and heart infections (endocarditis).
Over the last several years we have also seen fentanyl increasingly contaminate the drug supply. In the past few months we have noticed an increase in self-reported overdoses requiring multiple doses of naloxone and increased reporting of overdose-related deaths among our participants. PWUD are most commonly the first responders in overdose events, with over 90% of naloxone administered by drug users for drug users (according to a 2013 article by Dr. Walley of Boston University). The pandemic may disrupt the ability of drug users to gain access to naloxone. With the naloxone supply chain interrupted and first-responder services and hospitals overwhelmed, an increase in preventable overdose-related deaths would be a devastating consequence of our health care system’s inadequate preparation for this outbreak.
Finally, we cannot overlook the effects of the pandemic on people who are on Medication-Assisted Treatment (MAT) such as Suboxone (buprenorphine) or methadone. The withdrawal symptoms from MAT medications are pernicious, such that many people may choose to start using heroin again to avoid experiencing this medicalized dope sickness. People who have not used heroin for a while may have decreased tolerance, making accidental overdoses (on heroin that is now contaminated with fentanyl) more likely. Individuals who temporarily lose access to their medications and resume heroin use will not get to pick up where they left off; inducing MAT is both tedious to navigate and physically strenuous, with multiple barriers that prevent many from entering treatment even under non-pandemic circumstances. Generally, methadone patients who have not yet “earned” take-home doses through consistent, near-daily attendance and long-running drug testing compliance (difficult for those who continue to use drugs or struggle with access to transportation or payment) must go to the clinic six days a week to access their medication.
The excruciating symptoms that occur as a result of opioid withdrawal—including body aches, fever, stomach cramps, vomiting—cause methadone patients to wait in long, often crowded lines for their daily dose: a process wherein social distancing is impossible. Patients have been directed to bring lock boxes to the clinic daily to be prepared for receiving extended take-home medications, but most patients have yet to receive any supply or any clear information on when or if that will happen. The administration that oversees national clinic regulations is in communication with state authorities and clinic personnel to allow for take-home exceptions, allowing patients to receive two weeks or a month supply of doses. However, states and clinics are allowed to enforce stricter regulations than is required of them, making it unclear who is responsible for keeping patients attending the clinic throughout the week. Louisiana compels methadone patients who have not met the aforementioned requirements to still go to the clinic every other day. At the time of this writing, the Urban Survivor’s Union is organizing with drug users and harm reduction groups to strategize and make demands on take-home policy nationwide.
Trystereo’s Response
Though social distancing measures are now necessary to slow the spread of COVID-19, an unfortunate side effect is that Trystereo and our colleagues at Women With A Vision (WWAV) and New Orleans Syringe Access Program (NOSAP) are now more limited in our ability to conduct our weekly supply drop-ins. Knowing that the weekly drop-ins that serve the majority of our participants may have to stop for the foreseeable future, Trystereo members mobilized to create a pandemic response protocol.
Between March 16 and 17, Trystereo held two drop-ins and distributed approximately 15,500 syringes, 1405 doses of naloxone for overdose reversal, and 485 safer injection kits to approximately 110 people. We also created PSAs on our website and social media platforms to alert the community about the shift in changing drop-in scheduling throughout this time, the potential risk of increased COVID-19 infection in people who smoke their drugs, and information on preventive measures to increase safe drug use.
At the time of this writing Trystereo will still be arranging supply deliveries via our text hotline (504-535-4766), following our pandemic response protocol closely. The reality is, though, that we are all limited by our resources, current laws, and evolving local and national guidelines related to COVID-19. This pandemic has, once again, exposed the need for harm reduction in public health, medical, and social systems—and not only in times of emergency.
What Comes Next?
This pandemic is not the first, nor last, disaster in human history. We are not completely without hope or resolve. The activism that arose during the AIDS epidemic in the 1980s led to advances in drug development, public health, and patient advocacy. It also laid the foundation for our very own harm reduction movement. We cannot control natural occurrences such as viral outbreaks but we can prevent them from becoming human-made disasters created by inequities and corruption. In every human-made disaster, from hurricanes to viral outbreaks, we are in awe of the limitless power of human cooperation as evidenced by the spontaneous eruption of mutual aid networks to help out others in need. Mutual aid efforts bring people from many backgrounds together for one purpose: to help people who need it. Thus, in times of crisis, rather than fearing widespread social disorder, we should instead revel in this demonstration of human potential unencumbered by systems such as capitalism and nation-state hierarchies that ultimately enforce social disorder on a daily basis.
Written by Trystereo Volunteers Mary Beth Campbell, Alex Niculescu, and Hana Dziuban, with help from Crow Lopez, Jen Stovall and Alix Jason. For more info (including details on Trystereo) go to trystereo.org/blog.