As COVID-19 continues to paralyze much of the world, people who use drugs wrestle with a collision of public health emergencies. Combining the overdose crisis, HIV and hepatitis C epidemics, chronic homelessness and mass incarceration with social distancing rules has created an especially noxious syndemic.
With accidental overdose still the most acute life-threatening risk to people who use drugs—and in-person harm reduction programs or healthcare widely curtailed or shut down—there is an urgent need for innovation.
People who use drugs have looked out for each other and kept each other safe since long before government-run services swooped in. And the pandemic has likewise moved community groups to use technology to help address service gaps that put people who use drugs at increased risk.
One early action was to create a list of “substance use spotters” for people in isolation.
The “COVID-19 harm reduction/pwud support” group, for example, was created to unite drug users and harm reductionists across Canada. One of its early actions was to create a list of people willing to act as “substance use spotters” for those in isolation.
Substance use spotting is a way to prevent overdose deaths. If a person wants to reduce the risk of using alone, they can ask a “spotter” to observe them while they use their drug of choice, either by phone or video call. If the person becomes unresponsive, the spotter can call an emergency responder or other preferred contact.
Virtual (or distance) spotting is well positioned—at any time—to lead overdose prevention efforts, particularly in suburban and rural areas, or among people who are compelled to use drugs in secret.
Global harm reduction messaging is fairly consistent wherever you go: Use sterile equipment, carry naloxone, start low and don’t use alone. But no one ever really explains how not to use alone. The short answer would be to have someone close by while using; the long answer is that social stigma around substance use often doesn’t allow for that to happen.
Community and technological innovations that have emerged and expanded in these times may continue to reach the people who are dying alone at staggering rates long after lockdown ends.
In Vancouver, British Columbia, as the pandemic accelerated the pre-existing need for remote overdose solutions, Brave Technology Co-operative released its free BeSafe overdose prevention app—defined as “an app for people using alone”—ahead of schedule.
BeSafe preserves the caller’s anonymity, unless an emergency responder is needed.
Brave was conceived in 2016 and emerged as an innovator in the prevention of overdose deaths. As a cooperative, its organizational structure is designed to uphold principles of economic justice and accountability to the community. As such, the co-op gives share-holding and voter benefits to its workers, investors and those who use its products. Among Brave’s previously developed tools are its Brave Buttons—devices that can summon help in overdose or other emergency situations, designed for use in multi-unit supportive housing.
BeSafe app users can train to become “supporters,” available to answer calls from a person who wants to mitigate their risk of overdose. Informed by an understanding of the role of stigma in overdose deaths, BeSafe preserves the caller’s anonymity, unless an emergency responder is needed—in which case, the caller’s address is revealed.
Brave similarly garners trust by not gathering user data. Although anyone can download and use the app, BeSafe allows users to create private communities and empowers members to designate their own preferred responders, rather than rely on 911.
“Basically, we don’t want to know who you are,” Gordon Casey, Brave’s founder and CEO, told Filter.
Yet interestingly, community organizing has become the leading function of the app at this early stage, beyond—but closely linked to—its primary purpose of preventing deaths.
“I see the community function in the app as a way in which groups, who are already supporting each other in the crisis, can activate their specific style of support for each other in isolation,” Brave COO Oona Krieg told Filter.
With downloads in countries from Scotland to Australia, Brave is working to help users of the app tailor functionality to their region’s specific needs. “Once you have something that works a little, you can keep tweaking it to work more, and for more people, and in more places and contexts.” Casey said, adding that Brave designed the BeSafe app with an awareness of the global impacts of criminalization.
Brave is also encouraging feedback to address BeSafe’s current limitations. “This is just a tool,” Casey said. “It needs improvement, and we are here to listen and make those improvements so it’s going to work for as many people as possible.”
The Canadian Association of People Who Use Drugs (CAPUD) has many members with experience witnessing people who use drugs online. Recently, CAPUD’s executive director, Natasha Touesnard, has advocated for a 24/7 online overdose prevention site (OPS, also known as safe consumption sites).
“Drug users understand how to interact with each other while using substances. That’s something you can’t teach.”
“Online witnessing is a relatively new practice,” Touesnard told Filter. But the option gives drug users “a safe place to use from a distance.”
While she isn’t very familiar with the BeSafe app, Tousenard said she has downloaded it and intends to find out more. “With the staggering amount of overdose deaths in Canada over the last three years,” she said, “I welcome any and all interventions to stop people who use drugs from dying.”
Touesnard stressed that services like these should be run by people who use drugs. “Drug users understand how to interact with each other while using substances. That’s something you can’t teach.”
So what about life after COVID-19? Can witnessing technology be expanded to fill gaps in overdose prevention for rural and under-serviced areas, and marginalized populations? Can the BeSafe app, or its descendants, grow into a trusted life saving tool for millions of people who use drugs alone—including, for example, those in abstinence-based recovery programs or carceral settings?
There won’t be one solution for everyone. It is important to remember, for one thing, that many people have limited or no internet access. But we get closer to the solution when people at risk of overdose death drive the design process.
“The people most adversely affected by design decisions tend to have the least influence on those decisions,” noted Krieg. Given this reality, she said, it is imperative that innovators build solutions by “center[ing] the voices of those impacted by the overdose crisis.”
We have the technology to do this. It’s time to create a global community to keep each other safe remotely, for now and for the future.
Centering impacted voices at every step may take time and energy. But failing to do so will reduce the effectiveness of community interventions and cost lives. People with resources and privilege must realize that the gross power imbalances inherent to the class structure create the conditions that cause deaths. They must elevate those who have been stigmatized and disempowered.
The overdose crisis has no single answer. Universal access to a safe supply of opioids and other drugs, for example, is vital. So is naloxone. So are legalization or decriminalization. But utilizing technology to mitigate the risks of using alone can be another powerful blow against the war on people who use drugs.
Photograph by Elizabeth Van Assum courtesy of Brave Technology Co-operative.