key: cord-0988177-lm28pkn7
authors: Efunnuga, Henrietta; Higgs, Peter; Walker, Shelley; O'Keefe, Daniel
title: Health service utilisation and access for people who inject drugs during COVID‐19
date: 2022-03-09
journal: Drug Alcohol Rev
DOI: 10.1111/dar.13456
sha: 6379d5d34be21b036f6b6f1032f9a7d6ef128561
doc_id: 988177
cord_uid: lm28pkn7

INTRODUCTION: The wide‐spread implementation of interventions to limit transmission and public health consequences of COVID‐19 in the Australian state of Victoria had flow‐on consequences for people who use and inject drugs. Consequences included the interruption of illicit drug supply and drug procurement, and the disruption to the delivery of health services. To inform strategies that can minimise the adverse outcomes of similar future disruptive events, this study explored how COVID‐19 restrictions impacted access to harm reduction and drug treatment services for people who inject drugs in Melbourne, Victoria. METHODS: Qualitative semi‐structured interviews were conducted via an online calling app, with 11 participants of a broader cohort study (the SuperMIX study) in April 2020. Interviews were focused on participants experiences of accessing and using harm reduction and drug treatment services. Data were thematically analysed using a process of blended coding. RESULTS: Findings revealed how disruptions in the delivery of harm reduction and drug treatment services—in response to COVID‐19 restrictions—created barriers accessing sterile injecting equipment, increased risk of arrest by police and exacerbated social isolation. Participants reported difficulties adapting to changes in services access, with some increases in injecting risk behaviours. However, improvements in opioid agonist therapy prescriptions were noted as a beneficial outcome. DISCUSSION: By examining the impacts of COVID‐19 and the resultant restrictions on people who inject drugs' access to health services in Melbourne, Victoria, findings provide guidance for future responses to the unanticipated large‐scale effects of the COVID‐19 pandemic, and similar disruptive events.

The COVID-19 pandemic is a major global public health concern. In Australia, low death rates have been attributed to early interventions, including border closures and strict restrictions on social and physical interactions [1] . By interrupting illicit drug supply and drug procurement [2] , these interventions, however, had flow-on consequences for people who use and inject drugs, including the potential for increased injecting risk behaviours, overdose and drug diversion, and disruptions in the nature and delivery of health services [3] [4] [5] [6] .

Population estimates from the most recent National Drugs Strategy Household Survey found an estimated 1.5% of people over the age of 14 report having injected drugs at some point in their lifetime [7] . People who inject drugs are at an increased risk of experiencing poorer health outcomes, such as increased risk of overdose and the transmission of blood-borne viral infections [8] , in comparison to those using drugs via other routes of administration. Furthermore, chronic concomitant comorbidities, such as pulmonary, cardiovascular and cerebrovascular diseases, mental health problems and compromised immunity, increase the risk of severe COVID-19-related complications (including COVID-19-related mortality) [2] [3] [4] .

The severely disrupting nature of the COVID-19 pandemic and consequent response measures are not without precedent. The impact of major disasters such as the September 11 attacks and Hurricane Sandy in New York City [9] [10] [11] , and the Christchurch earthquake in New Zealand [12] have previously been examined to assess interruptions to needle syringe programs (NSP) and opioid agonist treatment (OAT), representing the two primary interventions to reduce harms associated with injecting drug use. Research conducted with people who inject drugs (n = 300) after the events of Hurricane Sandy reported 60% of participants experienced withdrawal, 27% reported sharing needles/syringes with other individuals and 70% were unable to access sufficient doses of OAT [11] . Following the first outbreak of COVID-19 in March 2020, the Victorian state government moved to enforce a series of lockdowns to minimise social and public gatherings, which continued intermittently throughout 2020 and 2021, often for extended periods. Curfews, movement restrictions and shutdown of all establishments deemed non-essential were among measures introduced to reduce COVID-19 transmission [13] -broad containment responses that were anticipated to have potentially negative effects on access to harm reduction interventions for people who inject drugs [14] . Of particular concern is that reduced access to NSPs may increase receptive needle and syringe sharing and syringe re-use [15, 16] . Furthermore, the engagement in illegal activity (i.e. illicit drug procurement) increases the likelihood of drug-related arrest and fines for breaking COVID-19 restrictions for people who inject drugs, as police seek to enforce social distancing regulations on street-level pedestrian traffic and open-air public spaces [17] . The enforcement of physical distancing measures and restrictions on movement and gatherings, are likely to more adversely affect people who inject drugs, particularly those whose drug use is most visible, such as those who are also homeless [18] .

To inform strategies that minimise the adverse outcomes of similar disruptive events (including future COVID-19 control measures), this study aimed to understand the impact of COVID-19 restrictions on people who inject drugs' (in Melbourne, Victoria) access to and use of harm reduction services and drug treatment, including NSPs and OAT.

Qualitative methods, via semi-structured in-depth interviews, were used to provide in-depth insights based on participant views and experiences of COVID-19 restrictions.

Ethics approval for the study was granted by the Human Research Ethics Committee of La Trobe University, Melbourne, Victoria (#HEC20166).

Participants were purposively recruited via the Super-MIX prospective longitudinal cohort study, involving over 1300 people with histories of injecting drug use, in Melbourne, Victoria. The study was established in 2008 and examines the drug use, social and health trajectories of people who inject drugs. Participants of the study complete a survey every 12 months [19] .

Eligibility for this study was based on responses provided by SuperMIX participants in their most recent annual quantitative interview, including reporting changes in their OAT prescriptions or their access to NSPs since the introduction of the first COVID-19 restrictions in Victoria.

Eligible participants were contacted and briefed about the details of the project. An informed verbal consent process was conducted prior to interview and participants were reimbursed $40 for their time and expenses.

Individual in-depth interviews were conducted with 11 participants in April 2020. A semi-structured interview schedule was used to guide the interviews, which was informed by international literature about service access for people who inject drugs during significant disruptive events, as noted earlier. Interview questions were designed to understand how disruptions in the operation of harm reduction and drug treatment services in Melbourne, as a result of the COVID restrictions enforced across Victoria, impacted participant experiences. The interview schedule was flexible, to allow participants to discuss unanticipated topics of interest to them (although still broadly relevant to this study), that may otherwise have remained uncovered.

Participants were interviewed using the calling app (Skype). All interviews were audio-recorded and transcribed by the first author. All identifiable information was removed from transcripts and a pseudonym allocated to each participant. Data were stored securely on a password-protected laptop.

Interview data were analysed thematically. Data analysis was conducted using a process of blended coding, as described by Linneberg and Korsgaard [20] , whereby initial deductive codes were developed and manually by the lead author based on existing literature and topics in the interview schedule [20] . Subsequent codes and sub-codes were created inductively as patterns and themes were identified within the data; extracts from the transcripts were then coded to these [20] . All authors were consulted to ensure there was an agreement regarding the final themes presented in this manuscript.

The 11 participants interviewed for our study included eight men and three women, aged between 30 and 50 years. Two participants reported being currently employed. Ten participants lived in metropolitan Melbourne and one in a regional area of Victoria.

Data analysis revealed three themes: (i) disrupted access to NSPs; (ii) disrupted access to health services and OAT; and (iii) changes in drug use patterns. Interview extracts provided below are followed by a pseudonym and the gender and age of participants.

Participants described two primary barriers to accessing sterile injecting equipment. First, COVID-19 restrictions on individual movement and travel meant accessing NSPs was sometimes difficult. Second, although primary NSPs (needle and syringe distribution complimented by ancillary services, such as OAT, counselling or other social supports, specifically targeting people who inject drugs) remained open throughout the lockdowns as an essential service, some secondary NSPs (needle and syringe distribution via community health centres and hospitals) were closed. As noted by Troy some participants reported difficulty obtaining sterile needles and syringes because their usual services (a secondary site) were closed:

'I used to go to the community centre to get syringes when the centre was still open. After the start of COVID the centre was closed'. (Troy, male, 45 years)

Restrictions on movement (the Victorian Government imposed limits on non-essential travel from home) made it difficult for some participants to access NSPs when there were none open within their allowed 5 km radius. Although participants were permitted to travel outside of their travel radius to access sterile needle and syringes, as an 'essential service', some described noticing an increased police presence on Melbourne streets during lockdown periods, thereby increasing their risk of police interactions:

'One day I was stopped by the police-they know me. They just wanted to search my property for drugs, and they found marijuana on me. They said they wouldn't arrest me, but they took it, you know; I've been stopped several times'. (Ana, female, 33 years)

The enforcement of curfew rules also impacted operating hours for some mobile NSP services, and this meant participants were required to consider alternatives. For participants who were employed, the reduced hours of some services made it challenging to obtain sterile injecting equipment, as evening curfews were sometimes in effect after working hours, and they were reticent to access the delivery service during the day. As a result, some participants reported purchasing injecting equipment from pharmacies, or engaging in needle and syringe sharing:

'We used to get deliveries from Foot Patrol [mobile needle and syringe delivery service in Melbourne CBD] before COVID-19. We've been ringing Foot Patrol and get no answer for the past 3 months. There is no vending machine or NSP nearby at all. Now we go to the chemists to buy syringes. Once or twice we've had to use our own secondhand needles and syringes'. (Shaw, male, 41 years)

Having strong community connections and available peers meant that some participants, who could neither access a nearby NSP nor have access to mobile deliveries, did not go without sterile injecting equipment. In recounting his own experience accessing sterile needles and syringes, Chuck explained how important it was that he could rely on friends for sterile equipment. While for some, telehealth was preferred over physical visits, it did not always mean that the experience of telehealth consultations was positive. Tim described how he missed the usual in-person visits his GP would make to the community housing building in which he resided. These had been replaced with telehealth consultations:

'It's been difficult, yeah that has changed. We have a doctor from a medical centre in [a nearby suburb]. He used to come in here once a week on a Monday. But that's all stopped for the last four or five months. Now we have to do stuff over the phone and if anything is actually required, like face-to-face, I have to go over to his surgery which is a bugger'. (Tim, male, 42 years)

To better manage lockdown restrictions and reduce the opportunities for contact with COVID-19, many services increased the number of take-away OAT doses permitted. Some participants were able to collect 7 days of OAT medication in a single visit (previously, a maximum of four take-away doses was permitted), facilitating participants to maintain treatment while adhering to the rules of the lockdown:

'We get our doses for the week every Monday. We get the first dose and are given six take-away doses for the rest of the week 'til the following Monday'. (Shaw, male, 41 years) For some participants, changes to other essential health services were problematic, even if the service was still operating:

'I used to see a psychologist; I'm expecting a call-back because I've not been able to get a hold of her. Now she does telehealth consultations. Although it helps, I am not comfortable with that when my family is at home-I do not like to do that in front of them'. (Scarlett, female, 39 years) Furthermore, due to the pervasiveness of the lockdown Scarlett admitted to not knowing which services were open, which sometimes caused her anxiety:

'I'm pretty good with my health. With the COVID, I didn't think the dentist was up and running at all until I received a text from my dentist saying I was overdue for some check-up. With the GP, it's a bit tricky because of getting appointments and being aware if you have symptoms because you don't want to get someone else sick. I really haven't been able to see the doctor lately; they want to do everything by telehealth'. (Scarlett, female, 39 years)

Most participants reported changes in the frequency of their drug use in response to the COVID-19 restrictions. Uncertainty about how long the lockdowns would last was cited as an important influence on their drug use patterns whether it meant an increase or a decrease.

'My using changed due to the uncertainties surrounding the duration of the lockdown. Before the pandemic it was worsening, and it motivated me to get started on methadone. The lockdown affected my participation in the treatment programs and my using basically increased, yeah'. (Mae, female, 41 years) Due to changes in drug availability and accessibility, participants in this study reported illicit drug prices fluctuations, with some participants reporting a twofold increase in usual prices and subsequent financial constraints. As a result, some participants reported struggling to afford essentials, such as food. The need for some participants to purchase their injecting equipment from pharmacies only exacerbated these difficulties.

'I've run out of money many times having to pay more for the stuff. My payday is on a Friday and so for the next fortnight I'm literally operating on a litre of milk and a loaf of bread, and then another litre of milk, yeah'. (Tim, male, 42 years) Some participants (like Mae) described a decrease in the frequency of their use, citing the reduced potency of the illicit drug as a contributing factor.

'My using has decreased because the quality of the stuff has reduced'. (Troy, male, 45 years) However, for other participants, the isolation and boredom during lockdown increased their drug use: 'I've had times during the pandemic where I used more, and then during other times I used less. Due to price and quality issues, I thought I would have used less but I'm actually using more because there's been nothing else to do'. (Tim, male, 42 years) Furthermore, social isolation, in response to the COVID-19 lockdowns, was described as having substantial impacts on mental health. Some participants explained how increasing the frequency of their illicit drug use served as a coping mechanism for the lack of social interactions.

' I use mostly for the boredom now-there's no study, no stimulation, no interaction with people, the money isn't that great. It's like a coping mechanism. I am lucky I work because I would have used a great deal more if I wasn't'. (Scarlett, female, 39 years) Interviews revealed how NSPs served an important role beyond that of harm reduction, with many participants describing how they also provided opportunities for social interaction. With the lockdown, this opportunity was lost, particularly for those living alone. Consequently, boredom and feelings of isolation were significant factors that impacted the mental health of some participants:

'I live alone and feel isolated because I'm not able to do the things I used to and go to places I like. You can't go out the way you want to, or you will be pulled up. I guess that's why I am using more because it makes me depressed. I used to attend counselling groups, go to my mother's and brother's. I still go to the city and window-shop-it helps. Sometimes when I am depressed, I want to call up someone to talk about it, but it feels like I have no drive at all to make the move'. (Sean, male, 46 years)

This study provides insights into the impacts of COVID-19 restrictions on access to harm reduction services and other broader health supports for people who inject drugs.

Findings revealed how the introduction of curfews reduced the capacity of some NSP services (including mobile delivery services), which resulted in some participants no longer having a readily available source of sterile injecting equipment. This was an unwelcome addition to the already disrupted access as a result of Melbourne's mobility restrictions [5] . Similar observations were apparent for people using drugs in other settings including the UK, South Africa and Spain [21] [22] [23] .

For the participants of our study, this was further exacerbated by poor communication and lack of clarity regarding changes to relevant services (adapted opening and closing hours, and delivery times) which occurred as a result of lockdowns [6] . These challenges represented multiple risks for people who inject drugs when trying to obtain sterile equipment, such as the risk of police interaction as a result of travelling to NSPs. Added to this is the financial burden of purchasing syringes from pharmacies (which has been associated with insufficient needle and syringe coverage [24] ) and the sharing of used injecting equipment. Similar observations were reported in UK-based research, where shortages in supply of injecting equipment led to an increased prevalence of sharing and re-using injecting equipment [21] .

The restructuring of OAT provision, which allowed for increases in take-away dosing and electronic scripts for pharmacists, was a positive outcome for participants in our study, as has been highlighted in international studies [25] . Prior research has demonstrated multiple benefits of sustained OAT prescription for improving quality of life and in reducing hepatitis C incidence, criminal behaviour [26] [27] [28] , and overdose risk [29] , highlighting the imperative for continuing uninterrupted OAT provision. Furthermore, for many PWID in our study, their local NSPs often served as a source of social interaction and community engagement, especially for those who live alone. While some participants reported having strong social support systems, others reported feelings of isolation as a result of the restrictions. These negative emotions for some were a key influence in reported increases of drug use.

To help mitigate the negative consequences of COVID-19 restrictions, the introduction of disaster relief planning as a collaborative effort between NSPs, advocacy services for people who inject drugs, drug treatment organisations and government authorities, should be considered. Providing clear and concise information regarding access to health and support services has been shown to be a vital factor in informing decision-making processes for both clients and service providers in other settings [30] .

In the event of future emergencies like COVID-19, more information about changes in NSP opening hours-as well as any available alternate servicesshould be communicated via social media messaging on targeted Facebook pages, or flyers and banners placed in discreet but strategic locations where people who inject drugs are likely to frequent. This information should be provided in a clear and concise manner with people who use drugs being encouraged to participate in its dissemination. The key objective would be to ensure stable and extended access to at least one OAT dosing site and NSP service-an achievable step as demonstrated via increased outreach service provision, and a move well received by clients of services in Bristol, UK [21] .

Finally, we suggest the establishment of online peer support which could help to address the need for social interactions, something which participants in our study described as losing because of NSP service closures. Studies have shown that support groups of this kind can assist people in maintaining social connectedness and providing emotional support as effectively as face-to-face peer support groups [31, 32] . In addition, online peer support groups that are moderated by either a peer or a professional have been shown to be more effective in providing mental health support compared to nonmoderated online peer support groups [32, 33] .

This study has some limitations. Most importantly, interviews were conducted very early in the pandemic (April 2020) when services were still adapting. Changes in practice since the study implementation may have addressed the challenges detailed. The participants recruited were those who specifically reported changes in their levels of service access, meaning interviews do not represent the views those who did not experience any disruption. The sample size was restricted to participants residing in Melbourne, Victoria, which experienced the most severe COVID-19 responses and was not reflective of other Australian states or cities. Finally, interviews discussed immediate impacts of the COVID-19 restrictions; longterm impacts were not explored in this study.

This study explored the impacts of COVID-19 and its resultant restrictions on people who inject drugs' access to harm reduction and other health services. Findings suggest that the COVID-19 pandemic had both positive and negative impacts on participants, and that many were required to adapt to the different ways these services were now being offered. While these findings may not be reflective of the experience of all people who inject drugs, they do provide some guidance for future responses to the unanticipated large-scale effects of the COVID-19 pandemic, and similar future disruptive events that create barriers to service access.

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The SuperMIX study funded by the Colonial Foundation Trust and the NHMRC (#545891, #1126090). The authors gratefully acknowledge the support of the Victorian Operational Infrastructure Fund. The funders had no input into the work. PH has received investigator-driven research funding from Gilead Sciences and Abbvie for work on hepatitis C unrelated to this work. All other authors have nothing to declare. We would like to acknowledge the contribution of the Super-MIX participants, the Burnet Institute fieldwork team and supporting community services and organisations.