For the average non-essential worker, it might feel like the coronavirus has put the world on hold. But for people who use drugs and may be addicted, particularly those substances that can produce a physical dependency, there is no pressing pause. If you’re out of drugs and approaching withdrawal, scoring your next hit becomes the most essential of functions. The pandemic poses not only the threat of the virus itself, but also represents one more barrier to wellness for drug users—whether they seek to access a safe drug supply while using sterile equipment, to go through medically supervised detox, or to engage with evidence-based treatment.
Reports coming in from around the country suggest mixed outcomes. Some addiction medicine providers—like WorkIt Health*, a buprenorphine and naltrexone telemedicine prescriber currently practicing in New Jersey, Michigan and California—say they are seeing an influx of new patients since the virus hit, especially now that certain restrictions on telemedicine have been lifted. One law in particular—the Ryan Haight Act, enforced by the Drug Enforcement Administration (DEA)—previously required initial buprenorphine visits to be conducted in person. Since the DEA temporarily suspended the act in March to help providers comply with the Centers for Disease Control’s social distancing recommendations, getting patients started on buprenorphine has been easier than ever.
“I think it’s harder to be at home right now by yourself if you are struggling with drinking or using, so we are finding more people are reaching out for help,” said Kali Lux, the head of marketing for WorkIt Health. Lux also noted that health insurance providers have been more lenient and more willing to work with WorkIt as well. Because of the new, less restrictive requirements around remote buprenorphine prescribing, the company is expanding to Washington State and Alaska this week, and also working toward finalizing expansions into Florida and Texas in the near future.
One physician in hard-hit New York City told Filter that his hospital’s detox closed due to inability to staff it during the pandemic.
“We have gotten a lot of requests to go into those states from some of our health plan partners,” Lux explained. “I think they are larger sizewise, so even though there’s lots of treatment, there’s still people in rural areas who can’t get to the bigger city for treatment. In Michigan especially, where we had people coming in from all over the state before the Ryan Haight elimination, the rural population responded well to us because they don’t have buprenorphine in their county.”
She hypothesized that the rise in new patients was a combination of more people wanting alternatives to uncertain street drug supplies, needing extra support during this period of heightened anxiety and isolation, and taking advantage of no longer needing to find a ride to the first appointment.
But not everybody has access to treatment services, even with the expansions to telemedicine. Hospital detox and inpatient services have become scarce in some areas, with reports of facility closures or unwillingness to take on new patients. One physician in hard-hit New York City, speaking on condition of anonymity, told Filter that his hospital’s detox had closed due to inability to staff it during the pandemic.
Hugo Hanson, an emergency department physician in New York’s Hudson Valley, says that all hospital admissions in his network are down, but that detox admissions have seen less of a decrease relative to other services. However, those services were unavailable for a short period of time, leaving addiction patients in the area—particularly those without cars—stranded.
“For at least a week at one of my hospitals that does a significant amount of addiction services, detox was completely closed,” said Hanson, adding that it has since re-opened. “My hospital network covers this region for about an hour and a half…[and] there was no inpatient detox available… Generally for lower socioeconomic populations getting an hour and a half away is not possible sometimes, so the local services are really critical for this population.”
“The only affordable, cheap, low-cost or free detox in Portland closed.”
Other states have suffered similar impacts. “The only affordable, cheap, low-cost or free detox in Portland closed,” said Jesse Harvey, founder of the Church of Safe Injection, an unauthorized syringe distribution program in Maine. “I’ve heard that in many other places they are not taking admissions until COVID passes. The already existing bottleneck for people to get into recovery is even tighter. Left and right, services are disappearing.”
Joseph D’Orazio, an emergency department physician specializing in addiction medicine at Temple University’s hospital network in Philadelphia, reports that his hospital was continuing to serve people experiencing acute addiction, but that some inpatient facilities there are not accepting new referrals.
“Some of the inpatient rehab services who do inpatient detox are not taking people who have been admitted to hospital recently,” said D’Orazio. He also hasn’t personally noticed any interruption to drug sales. “I’m seeing people [who use drugs] sharing cigarettes and huddled together and things that just make me really cringe,” he said, though he also acknowledged observing presumed drug dealers wearing masks while engaging in transactions.
Marginalized populations are suffering from a relative lack of information about the virus. “For neighborhoods that distrust authority, whether it’s medical and healthcare systems, the federal government, police, all sorts of authority figures, they need to have a credible messenger telling them [social distancing is] the right thing to do,” D’Orzaio continued. “I think sometimes coming from people they don’t trust, the message is lost … I have talked to some patients who are not social distancing … and they say, ‘Yeah I hear there’s no coronavirus in Kensington,’ which is certainly not the case.”
People who use drugs are facing an uneven mix of supply-side issues right now. Various sources, including the DEA and cartel members, are reporting significant interruptions to illicit drug supplies. For consumers, this manifests as inconveniences like price hikes, and health hazards—like spiked or inconsistent product, or unavailability of the required drug.
“In terms of the drug supply, two things are happening,” said Shilo Jama, director of the People’s Harm Reduction Alliance, a grassroots syringe distribution and harm reduction organization run by drug users in the Pacific Northwest, with headquarters in Seattle, Washington. “One: It’s starting to get less and less, like drugs are harder to find. Two: People are cutting [drugs] more with other stuff so they can try to fortify it or spread it out a little more, so I think home detoxes are going to be a bigger deal.”
Jama observed that some Seattle-area substances are showing up cut with “weird stuff like hallucinogens and PCP and other things like that.” He stressed the importance of utilizing fentanyl testing strips, and free drug testing services like those provided by DanceSafe.
“Historically when we have seen supply side shocks like this…users reported large declines in purity, high increases in price, and time to buy lengthened,” said Bryce Pardo, an associate policy researcher at RAND Corporation who studies drug policy and supply. People used to procuring their drug of choice within a half hour might now have to chase a source for several hours, he described.
Pardo emphasized that although we can look toward prior supply interruptions for some insight, these cannot provide a true parallel to our current situation—the last pandemic, he noted, was over 100 years ago, and it will be several months before we get hard data about the overall picture from the DEA.
“We do know right now that China is a major provider of synthetic drugs and chemicals made for the purpose of making synthetic drugs like methamphetamine and fentanyl … Where [coronavirus] first struck was part of the industrial hub in china; the disruption there may have had broader downstream impact in the illicit supply of drugs,” Pardo hypothesized.
Supplies of legal drugs like nicotine and alcohol are also impacted. In states like Colorado, for example, vape store closures have made it much harder to access vaping supplies. Cigarettes remain widely available from businesses deemed essential, and there are fears that people will be forced to switch back to a much more harmful form of nicotine consumption.
Official warnings about supposed heightened COVID risks for vapers haven’t helped in that regard; on April 16, the Food and Drug Administration revised its position to admit that there is currently no evidence for such a link.
“People may not be aware they are at risk of alcohol withdrawal, and alcohol is less available than it was.”
Pennsylvania faced a unique situation last month when Governor Tom Wolf shuttered state liquor stores. Although beer and wine can still be purchased in grocery and convenience stores, hard liquors like whiskey and vodka are no longer available in the state. This sparked outcry from local harm reduction activists, who said the closures were bound to cause withdrawal in people with severe alcohol dependency.
“This puts people at risk of withdrawal, seizure, [delirium tremens], death, heart attack and stroke, because you can’t just cut off alcohol cold turkey like that,” said Kenneth Anderson, founder of Harm Reduction, Abstinence, and Moderation Support (HAMS), an advocacy and support organization. “In Pennsylvania, beer is still available in convenience stores, so we wrote [for Filter] about doing a beer taper and not stopping abruptly.”
“With the COVID response, we have a situation where people are isolated in their homes, they may not be aware they are at risk of alcohol withdrawal, and alcohol is less available than it was,” agreed Bill Stauffer, the executive director of the Pennsylvania Recovery Organization Alliance. “We are worried about the impact on medical institutions. What it’s going to look like when someone is in alcohol withdrawal is they are going to end up in our hospitals. The one thing as a nation we want to do right now is keep people away from the hospital if at all possible.”
The legality of alcohol means that, for many dependant drinkers in Pennsylvania, this may be the first time they are experiencing disruptions to their supply. As a result, some may not even realize they are dependant, and may have difficulty recognizing the symptoms of withdrawal, or the necessity for medical intervention before having a seizure or another life-threatening symptom of alcohol withdrawal. Stauffer said this is a problem he often sees in elderly people who have been drinking for much of their lives, and who sometimes learn of their dependency only after having a surgical procedure that forces them to stop drinking for a few days.
“Medical providers [need to be] thinking about this right now,” he said. “I think everybody has COVID on their mind, so when somebody calls in saying they’re nauseous, feverish and things like that, it actually could be alcohol withdrawal and not COVID.”
He got numerous reports from opioid-addicted patients turned away from hospitals because beds were needed for an expected flood of patients withdrawing from alcohol.
In the first weeks after the liquor store closures, Kevin Moore, a clinical psychologist and administrator at interstate treatment provider Crossroad Treatment Centers, got numerous reports from opioid-addicted patients saying they had been turned away from local hospitals while requesting detox services because the beds were needed for an expected flood of patients withdrawing from alcohol, which has a higher risk of being fatal.
Those reports have fallen this month, Moore said. “New Jersey and Delaware didn’t [close liquor sales] and Philadelphia sits next to both of those states, so basically there’s this whole new importing business that’s going on right now. It’s a little like Prohibition. So I think the immediate crisis in people that were detoxing from alcohol is kind of passed.” Still, Moore is continuing to hear stories here and there from patients who say they were turned away from detox.
Asked about this issue, D’Orazio said he had not heard about that happening at any of the Temple hospitals, nor at any of the inpatient detox facilities to which they occasionally refer patients. “That hasn’t been the case,” he said. “They’ve been withholding beds because they don’t want patients from the hospital because they are afraid of patients coming in with coronavirus and getting [other] patients sick right now.”
It’s not just scarcity of detox services that is hitting drug users during the pandemic. Some harm reduction providers are also closing their doors or limiting hours—although many others are finding ways to carry on. Reports of closures span coast to coast, including facilities in Washington State, California and Maine.
In Maine, Harvey says his church has been trying to pick up the slack left when the government needle exchange closed after an employee tested positive for COVID-19, then re-opened with limited hours, but it’s been difficult with limited supplies.
Despite some disruptions, “the pandemic isn’t stopping drug supply,” said Harvey. “Drugs are still there. People are still getting high; it’s just even more uncertain now what the drugs are and how to stay safe. People are … dying because of backward government policies.”
“I think it’s criminal to shut down at this point. I hope funders notice who shut down and who didn’t.”
Harm reduction providers who are continuing their work are critical of some of those who aren’t. “I think it’s criminal to shut down at this point. I hope funders notice who shut down and who didn’t,” said Jama. “If you’re a needle exchange that shuts down now, unless your staff have gotten the virus and you don’t have a means to open or your state gave you the order, there is no reason to shut down now. We have to leave these open; we can’t let another pandemic start because of our fears.”
“The homeless community have been rising to the occasion, looking out for each other, supporting each other, loving each other,” he added. “I can’t be prouder of that community … they’ve really shined in this crisis.”
Photograph via NeedPix/Public Domain
* The author has previously done freelance writing work for WorkIt Health.