The struggle of people who use drugs for survival, dignity and harm reduction in three counties in the COVID-19 era. Read the intriguing report of our intern, Hannah Taylor!
Internationally, COVID-19 increased vulnerabilities for people who use drugs. Some of the difficulties facing people who use drugs (PWUD) were location specific, while others were common across countries and contexts. This article covers interviews with three activists from Ukraine, Russia and Norway and shares their insights concerning the effects of COVID-19 on people who use drugs and the responses from the community and governmental levels.
Lessened service access
In most countries, some health services ceased and most became harder to access. Anton Basenko is a staff member of Alliance for Public Health and board member of the International Network of People who Use Drugs. He offered insights into the situation in Ukraine, where, though harm reduction services were still available, the hours and services offered changed. PWUD had to find out where to go and when to get materials or meet with a case or outreach worker. Increased complication of accessing services is one factor fueling a decrease in health seeking behavior among PWUD seen across Europe.
Basenko, a parent himself, shared that adapting to COVID-19 measures and accessing necessary harm reduction services posed even more challenges for parents, who had the double burden of managing their own and their children’s care.
At first, during Ukraine’s lockdown, those experiencing homelessness were stuck without options when people flocked to centers for shelter and food, which had even more limited capacity than usual.
In Russia, most state health services became unavailable, and harm reduction services, delivered by NGOs, also faced extreme difficulties. Maxim Malyshev, social work coordinator at the Andrey Rlykov foundation, spoke about the difficulties of administering harm reduction during COVID-19.
Though harm reduction services were scarce before the pandemic, the Andrey Rylkov foundation was able to reach 4,000 people annually, a reach which has been severely limited.
In Norway, it was extremely difficult for PWUD when businesses and services that they relied on closed down in early April. Many PWUD in Oslo rely on low-cost food and housing offers, but these options stopped. Both of Norway’s drug consumption rooms closed down during COVID-19, leading people to consume in more risky conditions and to dispose of materials publicly.
“It was really heavy for people,” shared Janne Andresen, activist and employee of the Organization for Humane Drug Policy (Foreningen for human narkotikapolitikk).
When Easter came, a generally difficult time for PWUD in Norway because it is a long holiday, the low-cost offers for food and temporary accommodation opened again. The salvation army started to give out soup and food to people. Additionally, health-checking services reopened as did the availability of treatment for sicknesses and abscesses.
“Things got so bad that things started to open again. Because the government saw what they were doing to people,” shared Andresen.
Economic and social hardship
In all three contexts, loss of income was a primary driver of COVID-19 related hardship. Many people who had legitimate income sources had to resort to crime or go without. In Oslo, many PWUD sell a magazine that employs almost 2,000 individuals. When it closed down, it was a shock to the community, leaving many without any income.
Financial hardship also led, in some cases, to those who had ceased drug use to start again, or to riskier use. On top of that, people’s usual social safety nets were compromised. In Russia, those who were parts of groups such as Alcoholics Anonymous or other groups stopped seeing their community. In isolation, drug use becomes riskier because if there is a health-related event such as an overdose, there may not be someone there to help.
For some, the epidemic fueled desperation. Andresen shares that in Oslo, the street drug environment was dangerous for some time, as rates of criminality increased, such as fighting, stabbing, or selling fake substances.
In Norway, there was a temporary expansion in availability for opioid substitution therapy, which Andresen and her husband benefitted from. After consulting with their primary care physician, they were prescribed morphine, which allowed them to avoid the street drug scene.
The availability of OST during this time mattered for individuals and for the community.
“It’s smarter to give people substitution medicine than not, because then they can stay inside…You can do like normal people do,” shared Andresen.
“Then there’s a few more that don’t spread the disease.”
However, Andresen stresses that the availability of OST during COVID-19 depended on one’s doctor’s willingness to prescribe. While they are fortunate to have an understanding and compassionate doctor, not all people who use drugs in Oslo or Norway could expect the same. Additionally, it can be difficult for people to get to the doctor for the chance of being prescribed OST. At the time that we spoke, the temporary prescription of morphine was ending.
During the COVID-19 lockdown, availability of take home OST in Ukraine expanded from about 50% to around 90% coverage. There were also new entrants to opioid substitution therapy because the economic hardships posed by COVID-19 which made it more difficult for people to purchase drugs.
However, the take-home dosages were only for 10 days in most places, so it was still necessary for OST patients to travel in order to collect their medication. When public transportation was made available to only essential passengers, like medical staff, this presented a huge difficulty for many PWUD. Ukranian cities tend to be sprawling and difficult to traverse, requiring individuals to reveal up to 40 kilometers to reach their OST site. Without access to public transport, reaching necessary services can become impossible for those who could not rely on personal vehicles or pay for taxis.
In response to this, after advocacy from PWUD organizations, OST patients in some localities were granted permits to access public transport, though the reach was limited.
For antiretroviral therapy for HIV-positive individuals, the service adapted to deliver the medicine by post or through couriers. Needles and syringes also began to be distributed in more meaningful quantities, so that people did not need to visit as often to collect these supplies. Hopefully, expanded access to take-home OST will also stay in place as will ARV by mail.
According to The European Monitoring Center for Drugs and Drug Addiction, some drug treatment experts across Europe believe there is potential that expanded access to OST during COVID-19 following relaxed regulations may be integrated into new national approaches after the pandemic subsides.
Malyshev shares that the Andrey Rylkov Foundation organization expanded their virtual presence during COVID-19. They have a large Telegram chat, which members turned to for social support and sharing resources during COVID-19.
The epidemic made some hard-to-reach populations a bit more accessible, such as younger recreational drug users and those who organize raves or own clubs. As Telegram became the primary way to reach their community, they were able to establish more contact with this group on the anonymous platform. The organization also provided psychological support online.
In general, Malyshev feels that the social ties among drug-related communities have become stronger, and that self-organization is evident in the way that harm reduction materials spread through these networks.
Similarly, in Ukraine, harm reduction NGOs introduced online consultations and The National Hotline on Drug Dependence and OST saw higher call volumes. Basenko believes that some of the services that NGOs began to provide during COVID-19 will remain, such as increased use of hotlines.
At the Organization for Humane Drug Policy, they began making bigger packages of supplies than usual. This meant more syringes and larger harm reduction kits, for example. Other organizations also began to give out supplies in Oslo, such as a bus that delivers syringes around the city.
Increased risk with buying drugs and policing
In the context of lockdown, every person’s movement is more visible. For those whose actions are criminalized and stigmatized, risk is always higher. In Russia, Malyshev shares, police used their increased power under COVID-19 to put pressure on drug users, who struggled to safely pick up drugs after purchasing them online. Similarly in Ukraine, there were instances of police using the power to enforce social distancing to target groups of PWUD who were gathered to access a service such as picking up clean syringes.
Basenko shares that the lockdown turned the streets into, “a white paper. Every step is very visible and can be controlled by policemen.”
Basenko added that people who use drugs also fear the gaze of other judgmental citizens and risk being beaten up when going to pick up drugs. As lockdowns are eased, and there are more people on the streets, this situation is getting slightly better.
In Norway, in contrast, Andresen shared that while police are present in the streets and also in the neighborhood where most drug purchasing and use takes place, their primary concern is making sure that PWUD respects social distancing guidelines to prevent the spread of COVID-19.
Need for continued attention and support
Andresen shared that, in her experience, COVID-19 led more people to realize the difficulties that people who use drugs face, though the attention was temporary. There was an upsurge in people buying the magazine that many people who use drugs in Oslo sell, out of a sense of compassion, but that also ended.
“I was on TV..and radio…People got to see how it really was. But you know, that lasts for 2 or 3 days, and then it’s forgotten again. Then you’re just another person on the street that’s “struggling,” as they so nicely say it.”
COVID-19 highlights the difficulties that people who use drugs face to maintain their health, safety and dignity. COVID-19 made existing vulnerabilities even clearer, highlighting the ills of criminalization and insufficient service provision. The ways that NGOs and, in limited cases, governments have reacted in order to respond to these increased difficulties provides learning opportunities that should be taken forward even after COVID-19. The importance of accessible OST, ART and safe materials cannot be overstated. Innovation also includes the integration of online service provision and telemedicine, though face-to-face services will always remain important. Street drug users tend to be hard for harm reduction services to reach, and in an era where much service provision goes online, they can be left behind.