What are the key challenges COVID-19 presents for people who currently use illicit drugs?
There are multiple challenges for people who currently use illicit drugs and more are emerging as the pandemic goes on. Some of the new regulations and social requirements are impossible for current users to abide by, like following the social distancing and self-isolation regulations. People who use illicit drugs have to go to needle and syringe programs (NSPs), methadone/suboxone dispensing units, and their dealer’s place or car.
The closure of detox and rehabilitation facilities has hit some people very hard. It can take months to get into a long term rehab and getting told that, "It was your turn but we cannot take new clients" can derail people. Losing your job or working from home leaves quite a few extra hours in the day where drugs can be consumed, and people are talking of having the evening drink at afternoon tea and the lunch time hit at morning tea.
Some people speak of positive changes to their circumstances; the extra money, the extra takeaways, the telemedicine script renewal. It begs the question, why can’t this always be the case?
Talk of a drought in drug availability with borders closed is worrying everyone in the different drug using communities, then add the inability to move quickly, it is making people antsy. For over a month Tasmania has seen a doubling of price for most drugs, while other places are more recently speaking of a drought related problem in doubling of price for heroin, and less potent meth products are available with a 30 per cent price increase in some places. Naturally, this is not across every network but in the main this the reality. The price of grass has increased dramatically.
This reminds me of the early 2000 drought when heroin disappeared almost overnight and more harmful substances were used. A huge increase in alcohol use was observed which we are hearing is happening now and an unmet need for benzos is apparent. The alcohol consumption is concerning due to its damage on the hep c infected liver at a time hep c treatment has been wound back. The challenge of benzos is related to social isolation, housing of homeless users which amounts to being placed in a single occupancy room and told not to have visitors provides an ideal situation for overdose. Just handing naloxone to people is not an adequate intervention for overdose prevention; you need more than one person. Numbers of vials given away does not indicate the usefulness of the activity as this needs to be reflected in the project outcomes.
Some people who use drugs rely on contact with people from the drug and alcohol sector, the free food, accommodation and NSP for their non drug related human interaction. The removal and savage reduction in access to services has been terrifying for some and inconvenient for others. Drug users rely on a large community of other users to complete the business of using drugs. People to score from, people to tell you who has the best dope, people you can contact to get more dope, people who will take the stuff you nick. Speaking of which, the acquisitive crime that supplements many user’s income has been effectively wiped out as everyone is home all the time and shops are closed.
In terms of social distancing, people can’t be two arms away when doing a transaction and some won’t let their drugs or money out of their hands until the face to face exchange. People do worry about the hygiene regimen of the dealer packaging up and if they breathe droplets into a package. One fabulous change is once you’ve run the gauntlet to get to the exchange site, most dealers are on time (a minor miracle) as they don’t want people standing around looking so very visible.
There has been little information that is useful for people who use drugs from the general population. There are so many individual related personal questions and most users have no way of getting answers as you can’t ask a doctor or worker about drug using related issues or you will lose takeaways or some other punishment in the majority of services.
People who use drugs in prison are in 23 hour lock down and riots have resulted in some prisons because of visits being banned. COVID-19 has enhanced the feeling of difference, the feeling of punishment and the feeling of being on the outer. Being kept in a facility that has the potential to be a COVID incubator awaiting trial and even those convicted of simple drug charges is highly disturbing for inmates.
A community of people who struggle to keep their behaviour quiet and unnoticed at the best of times are being forced into a position where their movements are out of sync with the rest of the community and the chance of being picked up by the police is greatly enhanced - every users nightmare!
How is AIVL currently supporting people who currently use drugs to manage these challenges?
AIVL does not provide direct services to clients, we provide information and support to our member organisations. We supported and signed on to the two COVID 19 open letters on the issue for prisons that the sector initiated.
We have instituted a series of teleconferences to keep our members up to date and help ensure all our information is accurate and consistent across the nation. A weekly call with members of the National Peer Network provides a mechanism for our peers to discuss what is happening in each jurisdiction and share ideas and responses. A weekly call with managers provides an organisational overview of how COVID-19 is impacting on the work of our members.
We connect members to latest information or webinars nationally and internationally and act as a clearing house for COVID-19. Our membership of the International Network of People Who Use Drugs (INPUD) provides us with information from other countries and responses that have been developed to deal with their situation. In most cases they are further into the pandemic and their situation far graver, but the information is extremely helpful as we can be in front of the situation as it develops here.
We have been collaborating with several institutions that are researching the effect of COVID-19 on our community to help ensure the research will provide real-world, useful information. Research into the positive and non-world-shattering changes to prescribing and takeaways will hopefully provide us with ammunition to advocate for these changes to become general practice. We are providing input to The Australasian Society for HIV, Viral Hepatitis and Sexual Health Medicine (ASHM) Taskforce and assisting with the development of various new guidelines to help ensure they are written in a way that emphasise best practise.
What is AIVL doing differently during the COVID-19 pandemic?
The only thing that hasn’t changed is our commitment to the drug using community of Australia. Virtually every other issue, factor, practice, policy and project has been turned on its head.
One of the essential factors that differentiates AIVL from other services is the connection to our community. In our personal lives many of us are experiencing the previously outlined issues, and work-related focus testing and general community connection has been hampered. This makes it difficult to focus test educational resources or get feedback on new ideas or policies. We have developed a myriad of ways to get community input without putting participants at risk. The usual expanded use of telecommunications, seeing people in quiet places one by one, asking others to help with the process, we are developing new methods of connecting with our community as time progresses. Our ability to interact with community in our personal lives remains the same so there is more crossover between work and home.
What can the research community do to support AIVL and other organisations that support people who use/have used illicit drugs?
This is a very important question, as you can imagine the research community has kicked into high gear wanting to access the drug using community. Institutions have different understandings of what community consultation means. This makes cooperation difficult at times. Coming to us when the research is already written and our endorsement is wanted puts AIVL in a difficult place as our community will not respond so willingly if we support inappropriate research tools.
Recently, members have been getting feedback about current research practice. People who use drugs are finding that generally the tool has question after question and highlights their personal deficiencies in standard demographic information that speak to their marginalisation, like; the age of leaving school, employment, using, criminal history, place of children and family connections. If research organisations could take note of this concern and develop tools that don’t elicit this gut-wrenching response, that would be an incredible asset to the community and its ability to participate in research.
AIVL understands tools have to be standardised but three decades later we are still hearing, "we are just tweaking a tool developed for a HIV project." These communities are so different that what is acceptable for the LGBTIQA+ community, is not appropriate for a member of the criminal cohort with little community acceptability, for example. Often, research is replicated by different places and asking our community to fill in yet another look-a-like survey for no money may be distressing and is annoying.
Closer contact with researchers would help as a plethora of COVID-19 research is in the pipeline. If there isn’t some sort of collaboration, people who use drugs simply won’t participate in endless surveys and AIVL has to be careful how much we ask of our members.
Research on the virus’ longevity and ability to be inactivated at any stage of the injecting process would be an example of real world targeted research that actually has some use. How COVID-19 is impacting on the amphetamine/ice community is barely visible so research into that community would be useful. Opiate users are easy to access and become a de facto indicator for all drug use. Also, ensure surveys can be completed on phones and tablets so people can respond then and there.
What are the practical measures people who currently use illicit drugs can take at this time?
Practical measures for consistent drug users need to be savvy. Here are some suggestions:
- Reading user group bulletins and encouraging discussion among peer networks as new information is arriving and new ways to deal with challenges emerge. Some in the community don’t have the time or means to access wider community news and won’t know the extent of the response, so ensure networks are constantly advised and updated.
- People who use drugs need to ask their dealer what measures they are taking to minimise transmission and try to make hygiene a community expectation where feasible. Encourage dealers to assist social distancing by meeting people at the door and the same when meeting someone in a car.
- Ask dealers to wear masks and gloves when bagging up.
- Now things are a little quieter in the testing labs, this is a perfect time for chronic users to do their treatment. To be rid of hepatitis C (hep C) means their body is in better shape to fight the virus if they get it.
- While telemedicine is one step, bloods still need to be done and those users who are living with elderly parents or people with other health related problems don’t want to be a risk for these vulnerable individuals. Point of care or home testing kits need to be available.
- Make use of any changes to opioid programs, access the takeaways, and use telemedicine - the more people that are on these programs the harder to remove them.
How can people who currently use drugs be supported long-term during the COVID-19 pandemic?
This is a huge complex question as support is needed at both the individual and structural level and many helpful measures are not being introduced due to endemic discrimination. Understanding that the using community is not a homogenous community and issues discussed will impact on some cohorts more than others. The more stigmatising groups a person is connected to, the more negative impacts of COVID-19 will be experienced.
There has been no leadership from the drug and alcohol sector or the blood borne virus (BBV) sector in recognising the rather overwhelming issues COVID-19 has brought to the lives of people who use drugs. Visibility on the streets has disturbingly increased as the amount of travelling you need to do really stands out when everyone else is inside. Some sort of moratorium on charging people who use drugs if they are picked up for a COVID-19 violation while using drugs and not turning that interaction into further drug charges would be beneficial.
People who use drugs need support to expand the substitution programs to include dexamphetamine for amphetamine users and other programs as necessary. This will allow people to lessen their visibility and provide some meaningful support to that community who will have the same comorbidities and need help to ensure their health needs are acknowledged and treated. So many of the organisations and places you would refer people to are not open so there is a limited number of places our community can access. There are a considerable number of government related services users must have contact with for treatment (child protection, court, medical appointments, mental health) and cutting back unnecessary meetings would help. Services that are open need to think outside the business as usual response to current drug users and help users navigate new structural barriers, methods of discrimination and the sense of vulnerability these changes are having.
Understand the longer regulations are in place, the more impacts are noted and need to be dealt with so keep your eyes open to emerging issues in the using community. Structural based issues such as the criminalisation of drug users needs to be part of the conversation. The tone used to discuss people who use drugs in people’s personal lives, the media and workplaces has a huge impact on the way the wider community responds to this group.
Support people who use drugs by being open minded to the changes in takeaways and scripting, ask questions as to the acceptability of the current programs and their adherence to providing users programs that do not negate their human rights. The hep C treatment programs were summarily stopped yet this would appear to be a very good time for treatments to be started as non-drug related movement is curtailed and getting treated removes one comorbid health problem which must have a positive impact on the ability to fight COVID-19.
Encourage users to seek hep C treatment and ensure that it is available. If not, try and get it reinstated and ask for dried blood spot testing to be available. Check with the police to see if cooperation can be achieved for users getting fits and picking up so police can’t use those outings as a means of busting someone. Lobby for people in prison awaiting sentencing to be released, in fact anyone who is there for a drug related non-violent crime should be out. Being in jail is like sitting in the eye of the storm just waiting for it to arrive, people in prison understand the risk and wonder at the lack of compassion.
Where can people who currently use drugs get current and accurate information during the COVID-19 pandemic?
The COVID-19 pandemic has provided an environment which displays a real-world example of the success of peer networking and how quickly information can be disseminated and adopted. In early February, two INPUD members developed a pamphlet that outlines ways for users and dealers to avoid being picked up as they went about the business of drug use. The information was made available internationally and locally as groups interpreted the information for the issues and their community absorbed it. Two months later those community strategies are being reported in the news as methods users and dealers are using to bypass scrutiny.
For issues that are pertinent to the wider community, such as transmission rates and community transmission, the same vehicles the wider community uses are adequate. For issues that are specific to scoring, using and disposal, local user groups and peer networks will have information. Although users can’t travel much when borders are open, we want to ensure all the information we provide each other is accurate and similar so it’s not confusing or counterproductive. Some of the information that would be useful to us is the transmissibility of COVID-19 during the injecting process. Is it more useful for your dealer to use gloves or a mask? What time of day has the least amount of police on the roads?
A look at the many webinars and information put out by non-government organisations has alarmingly little information that is helpful to our community. The issues that surround injecting drugs would appear not to exist in most information from non-user groups other than some hep C related news.
AIVL's membership is instrumental in assisting us undertake our work. If you need any help with user related issues the contact for your local group can be found here http://aivl.org.au/aivl-member-organisations/