Harm reduction and COVID-19

 

The information on this page is based on currently available evidence related to the transmission and prevention of COVID-19 for people who use drugs. This resource was developed for direct service providers and includes considerations for harm reduction services to support clients during the pandemic. This resource will be updated as new evidence emerges. It was last updated March 12, 2021. 

For more general information about COVID-19, visit CATIE’s resource page for COVID-19.

How are people who use drugs at increased risk for severe illness from COVID-19?

People who use drugs in Canada are at increased risk for poor health outcomes during the COVID-19 pandemic. These impacts can be a direct result of infection with COVID-19. They can also be an unintended result of public health measures to prevent transmission of the virus that causes COVID-19, such as reduced access to services and the need to practise physical distancing, which in some cases have worsened the overdose crisis.

Impact of having COVID-19

COVID-19 is an illness that primarily affects the respiratory system. Individuals who already have some chronic health conditions are more likely to require hospital care and to die if they get COVID-19. People who use drugs are disproportionately more likely to have pre-existing chronic health conditions and are at increased risk of negative health outcomes, largely because of barriers to accessing healthcare.

In addition, there are some cases where drug use may directly increase the risk of severe illness from COVID-19:

  • Compromised breathing and lung function: Individuals who have compromised lung and pulmonary function may be at greater risk for severe illness from COVID-19. The use of opioids and/or methamphetamines can have an adverse effect on the lungs and respiratory system.
  • Depressive effect of opioids on breathing: Certain kinds of drugs, such as opioids, benzodiazepines and alcohol, have a depressive effect on breathing (they slow breathing down), which puts the user at a higher risk of having too little oxygen circulating in the body and reaching the brain, as well as overdose. Having respiratory symptoms from COVID-19 can worsen these effects.

What is the impact of having COVID-19 while using drugs?

COVID-19 may compound the effects of some types of drugs and/or affect the way they are ingested:

  • Smoking drugs and associated breathing difficulties: The respiratory effects of COVID-19 (dry cough, difficulty breathing) can make smoking difficult (e.g., nicotine, crack cocaine, crystal meth) and, in turn, smoking can worsen the breathing difficulties associated with COVID-19.
  • Changes to taste and smell: COVID-19 is associated with changes to taste and smell, which can affect the ability of a person to test their drugs.
  • Increased risk of overdose: The respiratory effects of COVID-19 can increase the risk of overdose death. COVID-19 affects the immune system and overall health, which may increase the risk of overdose. Further, there is a known risk of dying from an overdose for people who use opioids and have chronic respiratory disease, which can be made worse by COVID-19.

How do public health measures to prevent COVID-19 affect people who use drugs?

In some regions, efforts to prevent transmission of the virus that causes COVID-19 have had unintended consequences for people who use drugs, including reducing access to harm reduction and health services, increasing isolation, increasing the unpredictability of the illegal drug supply and increasing the risk of fatal overdoses.

  • Reduced access to harm reduction and other services: In many instances, regional measures put in place to reduce the transmission of the virus that causes COVID-19 have reduced access to face-to-face services for people who use drugs, including harm reduction and other services such as community health centres, outreach services and shelters. These services are essential for providing acute medical care, preventing overdose, fulfilling essential needs (e.g., food, shelter, social inclusion), distributing new drug use equipment to reduce the transmission of blood-borne viruses, such as hepatitis C and HIV, and linking people to care.
  • Increased isolation and decreased access to social supports: In many regions, the practice of physical distancing has resulted in greater isolation of people who use drugs, interrupted valuable social support and limited people’s opportunities to use drugs with others for the purposes of overdose prevention.
  • Increased unpredictability of the illegal drug supply and increased risk of overdose deaths: The illegal drug supply in Canada has been affected by measures put in place to reduce the transmission of the virus that causes COVID-19, including border and business closures. This has resulted in unintended changes to the illegal drug market; for example, the illegal drug supply has become increasingly unpredictable and toxic, the types of drugs that are available have changed and prices have increased. These changes have altered consumption patterns, the availability of supplies that people need, the locations where they are using, and withdrawal risk. These impacts, combined with a decrease in social supports and greater isolation have, most devastatingly, led to a marked increase in overdose deaths over the course of the pandemic.
  • Exacerbation of the affordable housing crisis: The pandemic has also exacerbated Canada’s affordable housing crisis, which disproportionately affects people who use drugs. People are having difficulty paying rent, and many shelters and drop-in programs have shut down or decreased their capacity. The congregate, high-density nature of many shelter settings increases the risk of transmission of the virus that causes COVID-19 because it is more difficult to physically distance or isolate. Further, temporary or emergency shelters are often located far away from services for harm reduction or overdose prevention. This geographic dislocation of people from services they depend on has led to increased overdose deaths in single-occupancy and emergency shelters.

The impacts listed above intersect with and reinforce one another. The emergence of the COVID-19 pandemic has exacerbated the ongoing overdose crisis, intensifying the challenges experienced by people who use drugs.

Practical considerations in addressing the impacts of COVID-19 on people who use drugs during the pandemic

How can the transmission of the virus be prevented while people are using drugs?

People use drugs for different reasons, in different ways and in different contexts. The following recommendations can help people to lower the risk of COVID-19 transmission when using drugs.

General prevention

Service providers should recommend to their clients that they combine the following general prevention methods to help prevent transmission:

  • Wear a new or clean face mask or face covering when you are in public and you may come into contact with others. You should also wear a new or clean face mask or face covering when you are in an indoor space with people not in your household or social circle. Social circles, sometimes called “bubbles”, are the limited groups of people that you have close physical contact with, including the members of your household and those outside your home. Some jurisdictions have made it mandatory to wear face masks or coverings in public areas.  When community transmission of the virus that causes COVID-19 is very high, it may be necessary for individuals to wear masks indoors and outdoors with people who are not part of their household.
  • Reduce your time in indoor spaces with people outside of your household or social circle, particularly if there is singing, shouting or heavy breathing (e.g. exercising).  
  • Maintain a distance of at least two meters from people outside your household or social circle to help prevent transmission of the virus.   
  • Wash your hands frequently with soap and water or use hand sanitizer to prevent transmission from contact with contaminated surfaces. Avoid touching your face with unwashed hands and regularly clean frequently touched surfaces with disinfectant. 
  • Get vaccinated for COVID-19 when the vaccine becomes available. Vaccination prevents severe illness from COVID-19 and it may also help to prevent transmission. People who have been vaccinated should still follow the prevention methods listed above.

Community transmission of COVID-19 will vary over time and between regions as the number of active cases rises and falls. When community transmission is very high, additional prevention measures may be recommended. People should consult their local public health authority for the latest guidance on how to prevent transmission of the virus that causes COVID-19.

Prevention during drug use

The biggest risk factor for transmission during drug use comes from prolonged exposure in enclosed spaces to someone who has the virus that causes COVID-19. Some considerations to prevent exposure include the following:

  • Limit contact with others if COVID-19 infection is possible or suspected. If a person feels unwell, has symptoms of COVID-19 or has recently been exposed to someone with COVID-19, they should avoid contact with others and self-isolate. They should consider if they need to be tested for COVID-19. The early symptoms of COVID-19 infection can be confused with symptoms of withdrawal or other illnesses. It is important to note that COVID-19 can be transmitted even when there are no symptoms. The safest approach is to assume that anyone could have COVID-19 and to protect against exposure.
  • Limit the size of social circles for drug use. Maintaining small social circles of regular partners for using drugs will help to limit the risk of exposure to COVID-19. Overdoses continue to be a risk for people who use drugs during the COVID-19 pandemic. Not using alone and carrying naloxone are the most important steps a person can take to reduce their risk of fatal overdose.

The following additional methods may help to prevent transmission of the virus that causes COVID-19, although their effectiveness in the context of drug use is not known: 

  • Use new equipment every time and do not share equipment with others. The sharing of drug use equipment is a potential route of transmission for the virus that causes COVID-19, particularly if the equipment has come in contact with respiratory droplets through contact with a person’s nose or mouth (straws, mouthpieces, pipes, cigarettes, bottles, lighters) or unwashed hands. Not sharing drug equipment and using new equipment every time will help prevent the transmission of the virus that causes COVID-19, as well as other viruses such as hepatitis C and HIV.
  • Wash hands before and after use and do not touch others’ equipment. Using general hygiene practices for equipment and spaces where drugs are used is an effective way to prevent the transmission of the virus that causes COVID-19. This includes washing hands before and after use, preparing drugs individually and not handling others’ equipment, keeping spaces clean with soap and water, and safely disposing of used equipment in a biohazard or sharps container. 
  • Ensure good ventilation in the spaces where drugs are being used with others. Prolonged exposure to other people in enclosed spaces increases the risk of transmission of the virus that causes COVID-19, even when physical distancing is maintained. If using with others in an enclosed space, individuals should also consider the use of face masks. Opening windows may help increase ventilation indoors.

What considerations are there for preventing and responding to an overdose during the COVID-19 pandemic?

The recommendations for preventing an overdose death and preventing the transmission of COVID-19 have in some cases conflicted with another. A prime example is that physical distancing and using drugs alone will decrease the risk of transmission of the virus that causes COVID-19 but increase the risk of death from overdose. To help individuals make informed decisions about their health during this time, it is important that frontline programs continue to share guidance on overdose prevention in a way that acknowledges the current context of the COVID-19 pandemic. This may include the following actions:

Make sure clients are up to date on public health recommendations.

  • Provide education and share up-to-date knowledge with clients and community members on general COVID-19 prevention, including recommending that people stay two metres apart, wear a mask, wash their hands regularly and keep their social contacts to a single household.
  • The amount of virus in a community may change over time and therefore approaches to prevention may also change. People should consult their local public health authority for the latest guidance on how to help prevent transmission of the virus.

Encourage people not to use alone and explore options for them to use with others.

  • Creating social circles of two, or using with one other person (preferably the same person each time), can be an effective way to reduce the risk of fatal overdose and decrease isolation.
  • For clients who use alone, using technology (phone, text, virtual calls) could be a helpful way to connect them to another person who will know when they’re using, check in to make sure they’re ok and connect them to emergency services if needed. Phone lines, where someone spots another person virtually, have become available across Canada and are an alternative to using alone.

Distribute naloxone.

  • Not using alone and carrying naloxone are the most important steps a person can take to reduce their risk of fatal overdose.
  • While having another person present will not reduce the risk of overdose, educating clients on how to use naloxone and encouraging them to be with someone who is able to respond in the case of an overdose is critical to preventing an overdose death.
  • It is also helpful to stagger use, so that people are not using at the same time and at any given time at least one person is capable of responding to an overdose.
  • Overdose prevention or supervised consumption services, where available, can also provide a safe place to use.

Ensure that clients and service providers know how to respond to an overdose.

  • Engaging in rescue breathing and chest compressions increases the risk of transmitting the virus that causes COVID-19, although these steps are critical in ensuring that a person who has overdosed receives oxygen and preventing brain damage.
  • If a person responds to an overdose, they should follow the SAVE ME steps.
  • Some considerations for reducing risk of respiratory contact when responding to an overdose include:
    • giving naloxone earlier to reverse an overdose, as opposed to waiting or giving breaths
    • performing “hands-only” CPR, wearing a face mask and using something to cover the face of the person receiving CPR

Refer clients to drug treatment programs.

  • Connecting clients to methadone or suboxone treatment and safer supply may help during this time.

How can frontline harm reduction services support clients during the COVID-19 pandemic?

The emergence of the COVID-19 pandemic has significantly disrupted the delivery of essential harm reduction services, and it has had variable impacts across Canada. A concerted effort to maintain and prioritize harm reduction services is essential to support people who use drugs during and beyond the COVID-19 pandemic.

Frontline programs across the country are adopting methods to deliver their services during the COVID-19 pandemic in ways that are increasingly innovative and low-threshold. Some practical examples of what frontline programs can do to continue supporting their clients during the COVID-19 pandemic include the following:

  • Scale up outreach and mobile services in the community, such as setting up temporary shelters and encampments and arranging delivery of new supplies and medications for clients in isolation.
  • Scale up harm reduction supports by facilitating access to a wide array of new drug use equipment and naloxone kits at different times and locations.
  • Help clients stay connected to harm reduction programming by phone or Internet.
  • Establish partnerships with other community services and provide multiple services in an integrated way.
  • Ensure that the basic needs (food, clothing, shelter) of clients are addressed.
  • Advise clients on how to prevent transmission of COVID-19 and to consider the impact of the pandemic on their use (e.g., equipment, drug supply, isolation) and other health care needs (e.g., medication).
  • Keep clients informed about interruptions to services.

There are a number of ways that frontline services can adapt to support their staff in the context of the COVID-19 pandemic, including the following:

  • Ensure a safe work environment that includes adherence to current infection prevention and control guidance for all service providers.
  • Keep up to date on the status of COVID-19 cases in the region, anticipate changes to operations and respond to challenges as they arise.
  • Increase access to social and mental health support for workers, including grief/bereavement services.
  • Ensure flexibility in scheduling and leave periods.
  • Engage staff and peers in planning and proposed changes, paying particular attention to the impact on peer workers of working during the pandemic.
  • Support access to COVID-19 testing, access to healthcare for individuals infected with COVID-19 and access to the COVID-19 vaccine.

What are some important considerations for clients at risk of and living with HIV and hepatitis C during the COVID-19 pandemic?

Hepatitis C

Hepatitis C is a virus that causes liver damage and disease over time. Hepatitis C is prevalent among people who inject drugs.

There is no strong evidence that having hepatitis C is associated with a higher risk of becoming infected with the virus that causes COVID-19 or having a more severe illness with COVID-19. However, if an individual has advanced liver disease (cirrhosis) as a result of their hepatitis C infection, they have an increased risk of severe illness and mortality if they contract COVID-19.

Experts consider the COVID-19 vaccine to be safe and effective for people with hepatitis C.

It is recommended that individuals with hepatitis C who have COVID-19 continue treatment for hepatitis C if they are already on treatment. Those with COVID-19 who have not yet initiated treatment for hepatitis C should hold off on starting until they no longer have COVID-19.

HIV

HIV is a virus that weakens the immune system, the body’s built-in defence against disease and illness. People who use drugs are disproportionately affected by HIV.

A person who is living with HIV who is on treatment, has a strong immune system and has an undetectable viral load is not expected to have a higher risk of becoming infected with the virus that cause COVID-19 or having a more severe illness with COVID-19.

There are three main risk factors that can increase the risk of serious illness from COVID-19 for people with HIV: a weakened immune system, underlying health conditions and older age.

Experts consider the COVID-19 vaccine to be safe and effective for people with HIV.

For more information, visit CATIE’s resource that has up-to-date information on COVID-19 for people living with HIV on how to manage their health during the COVID-19 pandemic.

The information on this page is based on available research related to the transmission and prevention of COVID-19. This resource will be updated as new evidence emerges. It was last updated on March 12, 2021. 

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