Between Waves: Update on the COVID-19 and Harm Reduction Situation in Europe

An update about how access to harm reduction programs changed in European cities after the lockdown measures were lifted between the first and second waves of the COVID-19 epidemic. 

Background:

After the introduction of lockdown measures in March, Drugreporter was at the forefront of monitoring and reporting the harm reduction situation in Europe. We interviewed service providers and activists from more than 30 European cities, created an updated info page, and launched Stories from the Frontlines, a series of live web-videos. In October we conducted an online survey with the objective of giving an overview of the current situation and finding out whether changes introduced during the lockdown still persist or not.

Themes and methods:

We distributed a short online questionnaire among a selected group of harm reduction service providers and activists (directly contacted online through email or messenger), covering all regions of Europe, to give us an update on the current situation (second half of October 2020). The survey focused on the following factors: 

1) There were several reports about the changes in the price, quality, and availability of illicit drugs due to travel restrictions and lockdown measures. We inquired as to whether this impact on drug markets was transitionary or longstanding;

2) Reduced access to/quality of harm reduction services were reported from most cities during the lockdown. We asked respondents about the situation now;

3) After the introduction of lockdown, several hospitals and health centres where people could access opiate substitution treatment (OST) were closed. Several OST programs introduced new, relaxed rules (increasing take-home periods and dosages). We asked if these relaxed rules were maintained or not;

4) Many people who use drugs lost their livelihood and/or homes/shelters during the COVID crisis and quarantine measures for this group proved to be a special challenge. In some cities special shelters were opened where homeless people who use drugs could access drugs/medications and could survive the shortages in food and water. We inquired as to whether these special shelters are still open; 

5) Prisoners were one of the most vulnerable groups during the COVID crisis and several organisations called for the early release of non-violent offenders. We asked if there were any such measures in the cities and if there were any outbreaks of COVID in prisons;

6) Drug consumption rooms had to adapt to the lockdown measures and reduce the risks of infections. Some of them closed, whilst others moved outdoors or operated with limited opening hours. We asked about the situation after the lockdown.

Limitations

This inquiry is based on the views of professional service providers, academic researchers, peers, and advocates who work in the field of harm reduction in European cities. These professionals have essential on-the-ground knowledge and experience with the current situation of harm reduction services and changes in the drug market. But this may not be comprehensive. Considering the great regional diversity in illicit drug markets and drug services within many countries, the respondents were asked to provide information on the situation in individual cities (with the exception of the prison situation, where we asked about the country-wide situation, as major prisons are often situated outside of cities). It is possible that other service providers or other groups of people who use drugs may have different experiences even in the same cities. Our respondent from Valletta informed us that her answers apply to the whole island of Malta due to the small size of the country.  

Findings

Thirty-two respondents from thirty-one European cities filled in the questionnaire. Twenty-one respondents were professional service providers, representing NGOs providing local harm reduction services (including needle and syringe programmes, drop-ins, street outreach services, HIV and HCV testing and counselling, drug consumption rooms, and drug checking services). Six respondents represented organisations of people who use drugs and/or young people who use drugs. Three respondents were academic researchers (who are in close contact with service providers and consulted with them before completing the questionnaire). Three respondents represented harm reduction networks/advocacy organisations with a national membership.   

The cities participating in the survey: Amsterdam (Netherlands), Antwerp (Belgium), Athens (Greece), Barcelona (Spain), Belgrade (Serbia), Berlin (Germany), Bratislava (Slovakia), Brussels (Belgium), Bucharest (Romania), Budapest (Hungary), Copenhagen (Denmark), Helsinki (Finland), Kyiv (Ukraine), Lisbon (Portugal), Ljubljana (Slovenia), Madrid (Spain), Podgorica (Montenegro), Porto (Portugal), Prague (Czech Republic), Rome (Italy), Riga (Latvia), Oslo (Norway), Sarajevo (Bosnia), Split (Croatia), Sofia (Bulgaria), Tallinn (Estonia), Valetta (Malta), Vilnius (Lithuania), Warsaw (Poland), Zenica (Bosnia), Zürich (Switzerland).

Are the prices/availability/quality of certain illicit drugs different from the pre-COVID situation?
Summary: Although many cities reported changes in the illicit drug market when the lockdown measures were introduced, these changes do not seem to be persistent in most cities and changes cannot be directly linked to COVID-related measures. The only consistent change is the reported increase in the price of cannabis in several cities.

Respondents from most cities did not report a difference between either the price or the quality or availability of illicit drugs compared to the pre-lockdown situation. A rise in cannabis price (compared to pre-lockdown price) was reported in Belgrade, Porto, Zurich, Oslo, Valetta, Podgorica, Rome, and Barcelona.  A shortage of cocaine at times was reported in Zurich, “because of increased controls of shipments and travel bans.” In Athens drug users reported reduced quality of illicit drugs but no change in drug prices. A reduction in cocaine prices was reported from Podgorica but this is a trend has started before the COVID epidemic. An increase in the quality of cocaine was reported in Ljubljana, but worsening quality was reported from Belgrade.

A change in the quality of new psychoactive substances was reported in Budapest, where a new, more potent synthetic cannabinoid receptor agonist hit the market in June, causing several lethal overdoses (unrelated to COVID). In Prague “the instability of the market” was reported as the main problem, with changes in quality and prices (increase) of certain drugs, such as methamphetamine, and shortage in buprenorphine. Similarly, a respondent from Estonia reported that “the illicit drugs market in Estonia is always in flux, it is difficult to determine which aspects of it have been affected by the COVID lockdown and border closures.” In Lisbon a study conducted by Kosmicare reported that there was a reduction in the perceived purity of cannabis, amphetamine, heroin, and ketamine among people who use drugs.

 

ILLICIT DRUG MARKET CHANGES (comparing the situation before and after lockdown)	CITIES
No permanent change reported	Kyiv, Bratislava, Warsaw, Riga, Antwerp, Amsterdam, Brussels, Copenhagen, Madrid, Tallinn, Sofia, Sarajevo, Berlin, Helsinki
Change in drug price reported (reduction: -, rise: +)	Belgrade (cannabis +), Porto (cannabis +, MDMA -, LSD -), Zurich (cannabis +), Oslo (cannabis +), Valetta (cannabis +), Podgorica (cannabis +, cocaine -), Rome (cannabis +), Barcelona (cannabis +), Zenica (cocaine -), Lisbon (cannabis +)
Change in quality reported (worsening: -, improvement: +)	Prague (methamphetamine -, buprenorphine -), Belgrade (cocaine -), Budapest (NPS +), Ljubljana (cocaine +), Podgorica (heroin -), Athens (not specified -) , Lisbon (cannabis -, amphetamine -, heroin -, ketamine -), Zenica (heroin -, cocaine +)
No information/unclear	Split, Bucharest, Vilnius

Are there any changes in the access to/quality of harm reduction services/equipment now compared to the pre-COVID situation?
Summary: Access to harm reduction is the same in most cities – but this means extremely low access in some cities. Most harm reduction centres remain open even during lockdowns but have adapted to the new situation, with some changes in their rules (reduced opening hours, restrictions on how many clients can come to a drop-in, etc.), which stayed in place even after the lockdown was lifted.   

In some cities in Central Eastern Europe, access to harm reduction programs (especially needle and syringe programs) was extremely low (below 50 needles per injecting drug user per year) even before the COVID epidemic, due to lack of funding and political support. In two cities, Sofia and Sarajevo, access to needle and syringe programs is reported to be zero.

Only a few outreach services distribute sterile injecting equipment in Budapest, Belgrade, and in Bucharest, with very low access. Severe reduction in access to harm reduction programs was reported from Madrid. In Athens access to harm reduction programs was significantly restricted after the lockdown but the situation has improved since then. In Berlin “only basic services (such as syringe/needles provision, warm meal to go) remained available. Counselling and HIV/HCV rapid testing is not available.”

The closure of heroin assisted treatment (HAT) was reported from Copenhagen during the lockdown but programs have reopened. A significant increase in access to harm reduction equipment (steering cups, filters etc.) was reported from Oslo. In Warsaw services were reopened in June after a three-month period of closure.

In Ljubljana it was reported that people who use drugs spend more time on the streets because of the limitations on how many people can come to the day-care centres. This causes nuisance on the street in front of opiate substitution treatment (OST) clinics and conflict between clients and service providers.

If rules of OST services were relaxed in your country due to the lockdown, were these relaxed rules maintained after lockdown measures were relaxed?
Summary: In most cities the original rules were reinstated after the lockdown, but in a small number of cities the relaxed measures were maintained.  

Some cities (Warsaw, Budapest, Sofia, Athens, Zenica, Zürich) reported that OST rules were relaxed, and that these relaxed rules were maintained after the lockdown. Interestingly, only one of these cities are in Western Europe.

In one city, Kyiv, quarantine measures were recently prolonged, and it is not clear whether the relaxed rules will stay after the end of lockdown. In Zurich, where OST rules were reported to be quite liberal even before the lockdown, the rules around heroin assisted treatment (HAT) were changed so that clients could take home up to 7 days’ worth of their medicine at once. In Tallinn the relaxed rules allowed all clients to take home 5-7 days’ worth of their medications, but this was changed after the lockdown. Now only those clients who are employed can take home 3-7 days’ worth of their medicine, whilst others should go to the clinic daily.

A drug user activist from Porto reported that the situation is mixed – some OST clinics introduced relaxed rules during the lockdown but most of them re-introduced stricter rules after the lockdown. In Lisbon OST services operated by NGOs did not relax their rules (daily uptake) during the lockdown, but rules at state clinics were relaxed (longer take-home period). However, it is not clear if these rules were maintained or not.

Respondents from Helsinki, Brussels, Riga, and Belgrade reported relaxation of OST rules, but it is not clear if the relaxed rules were maintained or not. As the respondent from Ljubljana pointed out, OST clients often gather on the streets around the OST centre because of the reduced access to day-care centres. In some cases, this leads to restrictions in the access to OST as a punishment for the nuisance they cause.

In Amsterdam people who use drugs with no health insurance could access OST, but this initiative was stopped after the end of the lockdown. Italian OST clinics were reported to be analysing the situation and discussing the possibility of relaxing the rules. In Podgorica the restriction on new admissions to OST programs was reported to have been maintained even after the lockdown.

The city of Copenhagen started a street-based outreach OST program, where opioid dependent users can start treatment at street level where they normally would have to come to the centre at a specific date and time, and from there attend daily for longer periods (to scale up to the needed dose and stabilise as a precondition to get take-home doses). This outreach initiative has proven to be very successful in enrolling users in OST. The municipality of Copenhagen has for now decided to prolong this initiative until the end of 2021.

RULES OF OST	CITIES
Not relaxed	Prague, Bucharest, Vilnius
Relaxed but restricted again	Oslo, Split, Antwerp, Amsterdam, Ljubljana, Copenhagen
Relaxed but not clear if maintained	Riga, Brussels, Belgrade
Mixed (up to services to decide)	Rome, Sofia, Tallinn, Lisbon, Helsinki
Relaxed and maintained	Bratislava, Kyiv, Warsaw, Budapest, Podgorica, Athens, Zürich
No information/unclear	Valetta, Madrid, Sarajevo

If special shelters were opened for homeless people who use drugs, what happened to these after the lockdown ended?
Summary: Special shelters were opened for homeless people who use drugs in several cities during the lockdown and many of them remained open even after the lockdown.

A service provider from Prague reported that special shelters were opened after the lockdown, and that these shelters are still open but are running at full capacity. Service providers are now working with the municipality to open new shelters for the second wave. In Bratislava an emergency shelter was opened for COVID positive/suspicious homeless people, it was open for people who use drugs, but this shelter was closed in August (update: the shelter was opened again on 1 November due to the second wave).

In Oslo a special shelter for homeless people who use drugs was opened but it was closed after the lockdown. In Amsterdam a service provider reported that “people who use drugs are back on the streets”, except those who tested positive for COVID (they are quarantined in special hostels). On the 1^st of September, temporary (3 months) housing facilities were opened for homeless people who use drugs where clients have access to OST and psycho-social support.

A special temporary night shelter (up to 24 hours) was opened in Ljubljana in April but it was closed in May. The government made a promise to re-open it if the crisis worsens. In Brussels “day care centres and different forms of housing options” were reported to be opened but there is still limited access to “affordable housing.” In Barcelona a special shelter for homeless people who use drugs was opened, and its operation is ensured until the end of 2020. A respondent from Sofia reported that no new shelters were opened, and that even the existing shelters closed down during the lockdown.

In Zurich the number of homeless people is estimated to be under 50 – most people who use drugs who experience homelessness have access to supported housing. Open air emergency shelters (tents) for people who use drugs were opened during lockdown.

Four emergency shelters were opened in Lisbon during the lockdown, where “harm reduction services were provided to ensure that the most vulnerable populations have access to the services they need, namely treatment to prevent alcohol withdrawal syndrome, opioid substitution treatment, mobile drug consumption rooms, needle and syringe program/crack pipes, training in overdose response, nasal naloxone distribution, and other health and social services.” The centres can host 220 people. Between March and October of 2020, approximately 700 people were hosted in Lisbon’s emergency shelters.

In Helsinki there is a permanent emergency night shelter for city residents who use drugs. It accommodates clients in shared rooms for a maximum of one night. Due to restrictions, there is queuing and overcrowding at the shelters. NGOs have provided some emergency accommodation (mostly targeted towards the traveller population and undocumented people, but also for PWUD) and some of the places offer warm seats (not beds). Due to the COVID restrictions there is a growing concern of what will happen when winter comes; the need for shelters is growing. PWUD have no adequate access to day-care centres. They are driven out of public spaces; i.e. from shopping malls.

EMERGENCY SHELTERS FOR PWUDs	CITIES
No emergency shelters for PWUDs	Bratislava, Kyiv, Warsaw, Budapest, Split, Podgorica, Riga, Sofia, Belgrade, Porto, Sarajevo, Bucharest, Berlin, Zenica, Vilnius
Special shelters opened but later closed	Oslo, Valetta, Ljubljana, Zurich
Special shelters opened and are still open	Prague, Antwerp, Amsterdam, Athens, Brussels, Copenhagen, Barcelona, Lisbon, Helsinki
No information/unclear	Madrid

Were there any measures securing the early release of non-violent drug offenders from prison due to COVID? Are there outbreaks of COVID in prison in your country?
Summary: Most countries introduced restrictive measures during the lockdown but did not follow international recommendations to release non-violent offenders.

As most respondents are professionals who work in the public health and social sector, they have a limited insight into the prison system. It was reported that most European prisons introduced restrictive measures during the lockdown, such as banning visits, ending educational, labour, and probation programs, and limiting the movement of prisoners inside prisons. Positive COVID cases were quarantined. Major COVID outbreaks were reported in Italy, a smaller outbreaks in Belgium, Denmark and Hungary.

Early release of prisoners was reported from Slovenia, Italy, Belgium, Spain, Germany, and Portugal. In Italy a small number of prisoners were released earlier from prison “after a dramatic period of riots and protests against the lockdown procedures.” These riots resulted in 13 deaths among inmates. The situation has stabilised since the lockdown ended.

PRISON SITUATION	CITIES
Major COVID outbreak in prisons	Italy
Early release of prisoners during lockdown	Slovenia, Italy, Belgium, Spain, Germany, Portugal
No early release of prisoners during lockdown reported	Hungary, Czech Republic, Ukraine, Slovakia, Malta, Croatia, Montenegro, Greece, Denmark, Bulgaria, Estonia, Romania, Finland, Bosnia, Lithuania, Norway
No information/unclear	Poland, The Netherlands, Latvia

If there are drug consumption rooms in your city, how has their operation changed after lockdown and are these changes maintained?
Summary: Only 7 cities reported that PWUD have access to DCRs. In most of these cities (with the exception of Oslo) DCRs remained opened with some limitations in the number of clients who can enter the facility and mandatory hygienic measures. These new measures remained in place after the lockdown.

In Oslo the drug consumption room (DCR) closed during the lockdown. Now it is open again, but with a limited (60 percent) capacity. In Amsterdam DCRs are open but with some restrictive measures. For example, the number of clients who can be at the DCR at the same time was limited to 6 clients maximum (from 18 clients before COVID). Hand washing and face masks are mandatory, as well as physical distancing (1.5meter). Smoking is prohibited inside.

Our respondent from Brussels reported that the first DCR there is scheduled to open in 2021. Our Danish respondent reported that “the number of drug users allowed to enter the drug consumption rooms was drastically reduced at the beginning of the COVID lockdown and has only slowly risen again,” and “are still slightly reduced.” Restrictions were introduced at smoking facilities within DCRs to avoid “social interaction” among drug inhalers/smokers (heroin/crack cocaine).

Limitations in access to DCRs in Barcelona were maintained after the lockdown. In Zurich three DCRs were reported to be closed for a few months during the lockdown but are now back in operation with expanded facilities where possible (e.g., an additional outdoor tent) to allow for physical distancing. The transition to the temporary outdoor site at the beginning of the pandemic has worked well and there was no day where people were unable to access the service.

In Berlin DCRs are reported to follow public health rules to prevent COVID infections, that is, they allow fewer clients to enter the facility. Smoking is only allowed outside the facility (in the backyard) to make more space for IV-users inside.

Lisbon has a mobile drug consumption room (the only one in the city and in the country). During the lockdown, the mobile DCR parked near the emergency shelters to support homeless PWUD. Since the shelters are still in place, there are no changes, the DCR is still supporting the emergency response in Lisbon.

Peter Sarosi