Impacts of the COVID-19 Pandemic on People Who Use Substances: What We Heard
Key Messages Expressed by Respondents
- People who use substances* report a loss of social connection and supports, as well as an increase in isolation, fear and anxiety as a result of the COVID-19 pandemic. Compared to the general population, they are more vulnerable to the health impacts of COVID-19 and the hardships of physical distancing.
- Respondents report a higher level of concern associated with the drug supply, its quality, degree of contamination, potency and cost, and their ability to access it given physical distancing recommendations. Risks are amplified due to reduced access to a range of services, including treatment and harm reduction services.
- COVID-19 exposes the shortcomings that have long existed for people who use substances in the type, access to and availability of healthcare and social services.
- Guidelines for the delivery of substance use treatment and services during a pandemic, such as those from the British Columbia Centre on Substance Use, should be developed in coordination with local healthcare and public health efforts to better support service providers and clients.
- Response measures must be informed by those with lived and living experience to leverage their expertise in developing realistic, creative solutions in both the immediate and medium term.
- Personal protective equipment must be part of harm reduction kits supplied to both people working in the field and people who use substances.
- Socio-structural conditions, such as unsafe or unstable housing, create underlying vulnerabilities to developing COVID-19 and substance use disorders.
- Both accidental overdose from substance poisoning and deaths during the COVID-19 pandemic can be reduced by increasing access to a safer drug supply.
Data for this report were generated from a qualitative design where 17 key informants were consulted using a convenience sample. The sample included 12 members of the Lived and Living Experience and Families and Friends (LLEAFF) Working Group coordinated by the Canadian Centre on Substance Use and Addiction (CCSA), and five representatives who provide harm reduction services from one of CCSA’s drug surveillance and monitoring projects (see Geographic Representation).
Respondents were invited to participate because of their trusted knowledge and professional experience in the substance use field, or because of having lived or living experience of substance use, or being a friend or family member of someone who uses substances. Semistructured consultation interviews, each about one hour long, were conducted virtually in April 2020. When the interviews were analyzed and coded using inductive analysis, four main themes emerged. These themes were identified independently by the three researchers involved in the project. This report presents and organizes the findings thematically.
Interview questions were developed to gain a better understanding of the experiences of people who use substances during the COVID-19 pandemic (see Interview Questions). Due to the small sample size, the findings presented in this report are not meant to be representative of the experiences of all people who use substances; rather, they are meant to invite discussion and further exploration of responses. Nevertheless, respondents brought depth and breadth of knowledge to the subject, as they collectively identified many gaps in healthcare and social services, and the urgency of addressing these gaps if we are to meet the needs of marginalized people during the pandemic and beyond. This resource is aimed at a general audience and is intended to increase awareness and understanding of the ongoing challenges and risks faced by people with lived and living experience of substance use, their families and friends, and by people who provide peer support and harm reduction services, as they navigate the day-to-day realities of managing substance use during the COVID-19 pandemic with strength and resilience.
What We Heard
All respondents discussed the interconnected effects COVID-19 has had on their lives. Pandemic response measures such as physical distancing and social isolation have disrupted the healthcare and support services that people who use or have used substances and their communities typically rely on. As a result, best practices that existed before the pandemic to promote well-being, such as not using substances alone and having peer responders for accidental overdose, were now seen as putting people at risk. These effects of COVID-19 have exposed or aggravated health vulnerabilities for those who use substances, but have also encouraged creative, resilient responses to care for their well-being during this time.
The following sections explore each of the four highlighted themes in greater detail, focusing on the multiple effects of the pandemic on the lives of people who use or have used substances and their families and friends, and how they are managing with the resources available to them.
Physical Distancing and Social Isolation
While the changes brought about by the COVID-19 pandemic may be challenging for us all, they are especially so for people who use substances. For the people involved in this consultation, COVID-19 has disrupted how they live, work and offer help and support to each other, how they communicate and how they establish meaningful connections with others.
Respondents identified physical distancing and social isolation as challenging for their mental health and wellbeing. The loss of social connection and supports, and of access to healthcare and support services, were the most frequently cited reasons for increased stress and anxiety.
Others found it hard to practice physical distancing and comply with public health recommendations because of their lifestyle, working conditions or living situation. They reported that being unable to follow recommended safety measures caused fear and negatively impacted mental health. Some reported that the pandemic has triggered suicidal ideations, night terrors and past traumas, including deep-seated emotions related to abandonment or the loss of a loved one. One respondent, a peer support worker, noted that the closure of libraries, shopping malls, restaurants and other public spaces has meant that people can no longer congregate or make the social connections and interactions that used to form the backbone of their social supports. Their imposed isolation from friends and networks means they celebrate or mourn alone their life events.
Especially for people who are street-involved, COVID-19 restrictions were reported to affect their very ability to survive. These effects include the loss of income because activities in the informal economy, including sex work, collecting spare change and recycling, have become more dangerous because of the need for physical distancing. In addition, the use of public spaces for shelter or drug consumption or simply to relax has become problematic since the outbreak of COVID-19. Respondents described that many people are experiencing increased distress due to police and private security enforcement of physical distancing.
Respondents reported that contradictory messaging around substance use before and during COVID19 has led to confusion and contributed to increased anxiety. For instance, before the pandemic, people were told as a harm reduction strategy never to use substances alone, as this helps protect them from an accidental overdose or contaminated supply. However, this guidance is now considered contrary to recommendations for COVID-19 prevention. People once told to use substances with others are now told to use substances alone to respect physical distancing recommendations. Some people using opioid agonist treatment are now given a week’s supply of the treatment (methadone) that they can use in isolation. While some respondents believed that providing a weekly supply to people while they are isolating was a good initiative, they also recognized that it could unintentionally increase the risk of harms or deaths related to substance use.
One respondent worried that street-involved people were not being provided with enough information on COVID-19 to make informed decisions about physical distancing and protecting their health. Similarly, another was worried that by not practicing physical distancing, a family member who uses substances was putting themselves and other family members at risk of contracting COVID-19.
One respondent noted that people in the justice system, especially those who are currently incarcerated, are being hit especially hard by COVID-19. Their inability to practice physical distancing in correctional institutions was a concern, as was the restriction on visits from family and friends.
Healthcare and Support Services
COVID-19 has led to the reduction in, loss of and other changes to services for people who use substances. These changes pose challenges for service providers and service users as they navigate the new reality and seek to minimize risks to themselves and others. All respondents noted that the pandemic has highlighted the gaps in healthcare systems and exposed the inequities that continue to exclude or marginalize vulnerable groups, such as people who use substances.
While treatment and service providers have done their best to adapt to changed circumstances, respondents noted many instances of cancelled services and a widespread lack of resources to adequately and effectively provide services. Lack of personal protective equipment (PPE) for service providers and people who use substances is of particular concern. As one respondent noted, lack of PPE for people who provide harm reduction and peer support services makes it difficult for them to respond safely to an accidental overdose. Indeed, at one residential treatment facility, staff were advised to call 911 in the event of an accidental overdose, and to avoid administering nasal naloxone or giving rescue breaths during CPR because of fears for staff safety. These potentially life saving practices are usually performed until first responders arrive.
The same respondent reported that it is not clear if administering nasal naloxone is an aerosolizing event that creates small airborne particles, hence fears around its use. Until this issue is clarified, only injectable naloxone should be administered. This concern highlights the need for accurate and up-to-date guidelines for providing substance use services along the continuum of services and supports during the pandemic, which was identified by several respondents. Because of risks, known and unknown, there is concern that those who would normally intervene in an accidental overdose will no longer do so because of fear of contracting the virus.
While providers have transitioned in-person meetings to online meetings, these are not sufficient to serve the number of people needing support. One respondent described a virtual meeting with over 200 people in attendance, making it impossible to provide any kind of personal attention. There is also concern that people are not taking care of themselves the way they did before the pandemic and out of fear are not seeking the supports they need. One respondent stated that they had lost half of their in-person cohort since switching to online meetings. This respondent also cited a loss of privacy as a concern for those people who might need to respond to a crisis at home while online. The majority of service providers noted that there is no substitute for face-to-face meetings, as these build connection and trust, and bring accountability to the relationship.
Of particular concern in the new COVID-19 reality is the number of people who are excluded from online services because they do not have access to a cellular device, computer or adequate Internet connection, or are unfamiliar with technology. Equally concerning is the number of services that have been cancelled or reduced, such as outreach, walk-in support services, supervised consumption sites, shelters and withdrawal services. Outreach services typically aim to reach people who are unable to or are uncomfortable seeking in-person services. One respondent noted that with fewer in-person services and more homebound individuals, outreach is needed now more than ever.
Service and treatment providers outlined the measures their agencies have taken to respond and adapt to the pandemic. Actions included preparing for an increased number of people withdrawing from substances due to disruptions in the illegal supply (Canadian Community Epidemiology Network on Drug Use, 2020); adapting services so that physical contact is limited (type of service, amount and mode of delivery for distributing harm reduction supplies); and providing supplies of naloxone as a preventative measure for anticipated overdoses. Others reported that changes to the recent opioid agonist treatment dispensing exemptions, including an increase in the availability and duration of prescribed take-home doses of medications, had the potential to improve access to these services for people who they would not normally reach. These include people not comfortable accessing services, those from rural or remote communities without pharmacies, and those with transportation issues or childcare responsibilities.
People who use substances may be more likely to contract or develop complications from COVID-19 compared to people who do not because of generally poorer health, compromised immunity or other underlying health problems. For some, the risk of contracting COVID-19 may be compounded by factors in the environment: marginal or overcrowded housing, lack of opportunities to maintain personal hygiene due to closure of public washrooms, and inability to practice physical distancing due to the need to seek substances. If they do contract the COVID-19 virus, they may be vulnerable to more severe complications due to suppressed immune function or respiratory issues brought on by using substances such as alcohol, cannabis or methamphetamine (Canadian Centre on Substance Use and Addiction, 2020a; 2020b).
Respondents reported that people who have been accessing recovery services for some time have well-established social supports and coping mechanisms. They reported managing the pandemic better than those who were new to recovery services or have not yet developed a support network. People in the latter group are vulnerable to returning to use because of anxiety and stress around isolation, disruption to services such as counselling and general uncertainty about the future.
The health of people who use substances can be disproportionately impacted by measures taken to address COVID-19. For instance, one respondent noted that inability to access services for opioid dependence (for example, having to wait for supervised consumption services) may result in opioid withdrawal, the extreme discomfort of which can lead someone experiencing it to use unsafe supplies in unsupervised spaces. As a number of respondents noted, the loss of social networks due to physical distancing measures combined with a constricted supply makes accessing street drugs during the pandemic especially dangerous. The supply might be from an unknown source and could be contaminated, lower in quality or different in potency.
Several respondents highlighted how service providers and people who use substances have adapted to the realities of the pandemic and devised creative ways to continue to support each other in spite of the challenges. They noted improved collaboration and communication among healthcare teams, drug user advocacy groups and people who use substances, both within and across these organizations and groups. Respondents also mentioned the interprovincial networks and organizations that have been sharing best practice guidelines for substance use during the pandemic. These networks enable regions to prepare responses based on evidence from other regions with different COVID-19 caseloads.
When supported in doing so, people who provide peer support services have the capacity and dedication to attend to the needs of their communities. One respondent noted that the residential treatment facility where he works has continued to operate throughout the crisis with almost a full complement of staff and commented that “recovery is not cancelled.” Another reported that switching to a virtual platform was a positive and affirming experience and improved the ability of his organization to reach people in remote areas.
What Needs to Be Done
All respondents pointed to access to a safer supply of substances as key to saving lives. Guidelines are needed to assist harm reduction organizations that are working with people who use substances and their families and friends to help them access and use safer supplies of drugs. Newly developed best-practice guidelines, such as those from the British Columbia Centre on Substance Use (2020), have been helpful to some respondents in delivering service. More work is needed to produce standard operating guidelines for service providers and the organizations in which they work. As one respondent noted, however, this will only save some lives, not all lives. We need to do a better job protecting vulnerable people by providing for basic needs (food, shelter, clothing, showers, income) and improved support and treatment options for people with substance use and concurrent mental health issues. Some needs can be addressed at the same time; for example, by expanding measures such as housing-based overdose prevention services.
Many respondents emphasized safe housing to meet the basic human need for stability as well as to provide protection from COVID-19. Safe housing is needed immediately to prevent large viral outbreaks among streetinvolved populations. Some respondents emphasized that any measures taken that have a positive impact should be prioritized and permanently implemented, even when the pandemic subsides.
Respondents said that the voices of people with lived and living experience of substance use and their families and friends should be prioritized during this crisis. These groups should be involved in the ongoing response planning for the pandemic, particularly for guidelines around isolation and physical distancing. Their involvement must be embedded within the larger, coordinated response among organizations that work with people who use substances, public health agencies that allocate resources for COVID-19 testing, and provincial, territorial and federal governments that distribute health funds and issue guidelines.
Several respondents involved in service delivery called for staff to be adequately trained and equipped with PPE to ensure their safety in the workplace. Ensuring access to PPE can help restore their capacity to provide the services offered by their organization, including outreach to meet people where they are, if they are isolating in their homes. Some personal protection supplies, such as gloves, masks, hand sanitizer, soap and alcohol swabs, should be included in the harm reduction supplies distributed to people who use substances. These supplies will improve the ability of those who use substances in groups or share supplies to look after their own health and prevent viral transmission.
Another respondent called for universal COVID-19 testing for street-involved people who use substances because of the high risk of infection and transmission created by comorbidities and environmental risk factors. Such testing would help protect these individuals as well as the service providers with whom they interact. The testing process should be as simple as possible to ensure those who use substances and have competing demands for daily survival have equitable access to testing and follow-up.
One respondent stated that the Internet should be available to everyone and should be recognized as an essential service. On a related note, community service providers should be encouraged to develop best practice guidelines for the provision of virtual care and increase their capacity to provide these services.
Against the backdrop of the ongoing opioid crisis and the broader COVID-19 pandemic, it is urgent that we acknowledge the needs of people who use substances and their families, friends and service providers, and meet these needs with proactive, coordinated measures. The pandemic has unveiled the health and mental health vulnerabilities of people who use substances. As a socially marginalized and stigmatized population, their vulnerabilities have always been present, but a global pandemic has brought the stark realities and needs of this community to the fore.
The interviews conducted for this consultation made clear the need for more and better resources so that people who use substances and their families and friends are supported and equipped to care for their personal health and well-being, and the well-being of their communities. As we have heard, many marginalized people have unmet needs — such as access to housing, safer substance supplies, treatment and supports, and basic income — that increase their vulnerability to the COVID-19 virus and the health inequities related to substance use.
Effective measures must be designed and delivered in consultation with the true experts: those with lived and living experience of substance use and their families and friends. These people have been crucial to the adaptative and creative responses that have arisen to meet the challenges of those who use substances. Such responses and further effective measures can improve the well-being of individuals who use substances and their communities during the pandemic and beyond.
As this consultation was informed by a relatively small sample of people with lived and living experience, their families and friends, and individuals involved in harm reduction, further consultation is needed with people across Canada as the COVID-19 pandemic evolves. This consultation can support positive outcomes among people who use substances. Despite experiencing a loss of social connection and supports and an increase in isolation, fear and anxiety, they continue to demonstrate resilience, creativity and strength as they navigate the new reality of substance use during a pandemic.