Disruptions caused by the COVID-19 pandemic may have been disproportionately harmful to people who use illicit drugs. Since March of 2020, the United States and Canada have experienced large increases in drug overdoses, overdose-related emergency department visits, and drug overdose deaths across multiple jurisdictions, particularly those involving stimulants and fentanyl . While the cause of this increase is not fully understood, and could be multi-factorial, disruptions in treatment and harm reduction services may have played a role. In particular, there may have been disruptions in access to medications for opioid use disorder and/or syringe service programs. Medications such as methadone and buprenorphine reduce risk of overdose and improve functional outcomes for people with opioid use disorder ; however, the COVID-19 pandemic may have disrupted access to these medications. For example, from May to June of 2020, one study of a sample of methadone clinics in the United States and Canada found more than 1 in 10 were not taking any new patients, with greater barriers to access in the United States than Canada . Another survey of drug users from Baltimore conducted between April and June of 2020 found fewer than half of respondents on methadone treatment had a four-week supply of methadone available . Syringe service programs,grow lights for cannabis where clients can obtain sterile syringes, reduce risk of HIV transmission among people who use drugs and may facilitate access to other essential health services for people who use drugs like substance use treatment and infectious disease treatment . However, the COVID-19 pandemic caused many syringe service programs to reduce services and sometimes to close .
Qualitative studies of people who use drugs in both the United States and Canada suggest that service disruptions, combined with fear of COVD-19, led some people who use drugs to reduce their use of health and harm reduction programs . The aggregate impact of these qualitative studies are corroborated by quantitative research showing visits to substance use treatment programs in 2020 were lower than the same time periods in 2019, with greater reductions in places experiencing more cases of COVID-19 . In summary, there is evidence the COVID-19 pandemic impeded access to important health services programs offering medicated treatment for opioid use disorder and syringe service programs, both because of reduced or disrupted operation of those programs, and also because program clients chose to avoid services because of fear of COVID-19. However, to date, there is no research documenting individual-level risk factors for eschewing or avoiding health and harm reduction services among people who use drugs. This in part reflects the challenge of recruiting and assessing risk in a sufficiently large sample of people who use drugs during a pandemic. However, understanding change in use of these services, and individual and community-level factors associated with this change, is key to future research that seeks to understand understanding how much and why outcomes related to infectious disease and overdose have changed among people who use drugs during the COVID-19 pandemic. However, understanding these risks is essential to mitigating their impact on service use, both in the context of the current ongoing COVID-19 pandemic, and in the event of future crises that result in significant societal disruption.
This study uses data from a subset of participants with a history of illicit drug use recruited from a consortium of cohort studies actively following more than 12,000 people in the United States and Canada to examine self-reported COVID-19 pandemic-related disruption in two harm reduction services—1) use of medications for opioid use disorder and 2) use of syringe service programs—among people who have injected drugs during the COVID-19 pandemic. We focus on a limited but important set of characteristics that were assessed in all cohort studies and either relate to core demographic characteristics or pandemic-related attitudes and behaviors . Data come from the Collaborating Consortium of Cohorts Producing NIDA Opportunities : a consortium of nine cohort studies with more than 6000 active participants funded in part or in full by the United States National Institute on Drug Abuse to study HIV/ AIDS and related outcomes in people who use drugs . The cohorts are spread across five cities in the United States and Canada: Baltimore, MD; Vancouver, BC; Miami, FL; Los Angeles, CA; and Chicago, IL. Recruitment and protocols for each cohort are described elsewhere . In response to the COVID-19 pandemic, investigators in each cohort deployed a supplemental questionnaire examining COVID-19 related factors such as disruptions to healthcare or harm reduction services resulting from the pandemic, self-reported history of COVID-19 testing or infection, self-reported history of vaccination and attitudes about vaccination, adoption of COVID-19 safety measures, and general mental health questions. C3PNO participants were recruited for participation in this supplemental survey if they had attended a regular study visit during the 12 months prior to March, 2020, and were able and willing to complete the interview remotely. Data were collected between May, 2020, and March, 2021. All data – including both the COVID-19 supplement and general study questionnaires – were collected through telephone interviews or online forms to accommodate social distancing precautions.
Participants received compensation for completing the interview. The study was approved by the institutional review/research ethics boards of the member cohorts and each participant provided informed consent for their study participation. Data from this analysis are drawn from two sub-samples of individuals who completed the C3PNO COVID-19 supplement: 1) To analyze disruptions in use of medication treatment for opioid use disorder, we included 702 participants who either a) reported any recent methadone treatment on their most recently completed study questionnaire or b) reported avoiding picking up medications for opioid use disorder, and c) for whom complete data was available for all other covariates of interest. 2) To analyze disruptions in syringe services program use, we included 304 participants who a) reported any injection drug use in the past month on their most recently completed study questionnaire, and b) for whom complete data was available for all other covariates of interest. Detailed dates of collection and response rates for each cohort and for the full survey are shown in Appendix A. The following characteristics were examined as potential self-reported correlates of avoidance of methadone dispensation programs and syringe-service programs: age sex , self-reported racial/ethnic group , homelessness status , high levels of worry about COVID-19 bottom three quartiles on 10-point Likert-type scale, top-quartile on a 10-point Likert-type scale self-reported stocking up on drugs in the past month , self-reported ever having been tested for COVID-19 , number of contacts interacted with to obtain or use drugs , number of sex partners , HIV status as of the most recent study visit where blood was drawn , cohort location , and date of survey completion . One covariate was different between the two outcomes: for the analysis of methadone dispensation avoidance, we examined self-reported use of any opioid other than as prescribed by a health professional ; for syringeservice avoidance, we examined self-reported injecting of opioids other than as prescribed by a health professional . In this analysis of 702 people who had been on methadone treatment in the United States and Canada, approximately one quarter reported avoiding picking up medications because of the COVID-19 pandemic. However,grow cannabis this number masks enormous disparities between countries and cities: in Vancouver, almost no respondents reported avoiding picking up medications for opioid use disorder, while in Chicago, Los Angeles, and Miami, most respondents did; Baltimore one-in-twelve reported avoidance. These wide disparities are consistent with other research on methadone access during the COVD-19 pandemic, and may reflect differences in regulatory context between Canada and the United States: in the United States, methadone can only be administered/ dispensed as specialty Opioid Treatment Programs , and buprenorphine can only be prescribed by physicians who complete special training and receive a waiver to do so. By contrast, in Canada, methadone treatment is more integrated into general medical care and can be prescribed or administered by many physicians and dispensed at pharmacies, and buprenorphine can be prescribed by any physician . Similarly, in Vancouver, local health authorities recognized substance use services to be essential services during the COVID-19 pandemic. Importantly, the United States made emergency policy changes during the COVID-19 pandemic, permitting states to in turn permit patients already initiated on methadone treatment to receive 14 or 28 days of take-home medication from an OTP, and permitting buprenorphine prescriptions to be initiated following a telemedicine visit with a licensed provider . There is evidence of widespread adoption of these options—including expanded use of telemedicine for addiction treatment and buprenorphine prescribing and expanded use of two- and four-week take-home methadone dispensation—with no accompanying evidence of reduction in care quality or harm to clients associated with this adoption .
Maintaining this enhanced flexibility—even after the need for acute social distancing to prevent transmission of the virus that causes COVID-19 dissipates—may be appropriate . After accounting for differences across jurisdiction, no individual characteristics were associated with self-reported avoidance of picking up medications for opioid use disorder. This suggests the local policy and service context was much more important for preserving access to these medications than characteristics of individual clients. The only exception was, in stratified analysis, in Baltimore—the only city with meaningful variation in self-reported avoidance of picking up medications—daily opioid use was strongly associated with not picking up medications. Unfortunately, this suggests one of two possibilities: either these individuals were least able to adapt to the changes in service use required by the pandemic, or conversely that not picking upmedication was a cause of daily drug use.Differences between jurisdictions were not as large for syringe service program avoidance. Sample size differences between cities, with Vancouver being the only city with more than 100 eligible respondents, make generalizing inference across jurisdictions difficult. In Vancouver, the only factors associated with syringe service avoidance were 1) being very worried about COVID-19 and 2) attending a study visit after October 1st. The former is self-explanatory. The latter is notable because COVID-19 incidence in British Columbia was substantially higher after October 1st than before , so these later respondents actually faced a more dangerous COVID-19 environment. Reduced avoidance of syringe service programs may reflect general numbing to the impacts of COVID-19, or improved safety practices from syringe service programs later in the pandemic. This study has a number of limitations. First, and most important, the majority of participants in C3PNO cohorts were not included in this analysis because they did not complete the COVID-19 supplement. Participants who did not complete the supplement—many of whom could not be reached during the pandemic—may have had different rates of avoidance of harm reduction services, and different risk factors for avoidance. Second, more generally, the participants of these cohort studies are not representative of people who use drugs in the United States and Canada, as all five studies are located in major metropolitan areas. Third, the large differences between cities in harm reduction avoidance make interpreting average avoidance prevalences and risk factors difficult. City-specific estimates are likely more interpretable. Fourth, sample sizes were small, making identification of significant differences for anything other than very substantial risk or protective factors difficult. Fifth, interpreting results of adjusted analysis from multiple regression in the absence of a causal hypothesis or analysis focused on a single risk factor of interesting is challenging . This is because some variables may mediate the effect of others on the outcome of interest; adjustment therefore blocks part of the causal pathway for some variables. In this analysis, adjusted results are important because they show most between-group differences in the outcome of interest are explained by differences in the distribution of those characteristics between cohort jurisdictions. However, odds ratios shown here should not be given a strict causal interpretation, and instead should be interpreted simply as the association of each risk factor with the outcome after adjusting for the presence of all other listed risk factors. Sixth, while we present crude and adjusted estimates for each covariate, we cannot rule out the possibility observed associations presented are confounded by unmeasured variables; an example might be underlying chronic disease risk which both increases risk for fear of COVID-19 and being unable to access needle exchange services. Seventh, not all cohorts collected pre-pandemic data on buprenorphine use.