Stay home and limit contact with others. This has been the public health mandate as COVID-19 cases increase across Canada. But for people who use drugs, this practice of social distancing could pose major dangers.
“Social distancing and using alone, the combination is terrible — it’s unbearable to even think about,” said Sarah Blyth, executive director of the Overdose Prevention Society in Vancouver.
Social distancing could disrupt the longstanding harm reduction advice of not using substances alone — especially in a city that has seen over 5,000 overdose deaths since 2016 because of a contaminated drug supply.
The province of B.C. is now in the midst of two public health emergencies. The first was declared over the overdose crisis in 2016. The second, declared on March 17 because of the COVID-19 pandemic, has led Blyth to anticipate even “scarier” circumstances.
The Overdose Prevention Society has continued operations while accommodating the mandate of social distancing. Right now, individuals can come into the site to use but have to quickly leave, with staff cleaning the area afterwards. But Blyth said that in the coming days, it could move to just helping individuals with supplies and ensuring they are safely monitored at a distance.
“We’re on the front line so just having to adjust how we do things, but the idea is to make sure that people live through this and or have the best chances to get through this crisis,” she said.
A few blocks away, the Vancouver Area Network of Drug Users (VANDU) is reducing the number of people accessing its services and attending its meetings.
For VANDU board member Laura Shaver, the need to safeguard against COVID-19 is also personal.
“I have a partner who has an extremely compromised immune system so we’re going to have to start protecting ourselves even more so because it could be very dangerous if I were to come home with anything,” she said.
B.C. is not alone in this challenge. Already occupied with the years-long overdose crisis, frontline workers and supervised consumption sites across Canada are now scrambling to handle two public health crises at once.
Ontario has been under a state of emergency since March 17 due to the COVID-19 crisis.
In response, Jennifer Ko, program manager of Moss Park Overdose Prevention Site in Toronto, said the site has had to reduce its capacity. It is also screening people at the door and modifying its space to have less of a “hangout zone.” Ko added that some staff are also in personal protective gear while working.
Similar measures are taking place at Regional HIV/AIDS Connection’s Carepoint facility, according to executive director Brian Lester. But he added that with the site being the only supervised consumption site in London, Carepoint is still running at full capacity and not seeing a significant decrease in clients.
“We have this COVID-19 pandemic, but there are two public health crises going on because we also continue to have the opioid crisis,” Lester said. “So we’re trying to respond to the original crisis with the marginalized folks that we serve, so we continue to operate our program at full capacity from 9 to 9, 365 days a year, and we’re committed to doing that.”
Quebec has recently confirmed hundreds of COVID-19 cases and just entered a three-week “pause,” where all non-essential businesses and services must close.
Jean-François Mary, executive director of CACTUS Montréal, said the site is implementing social distancing measures by lowering the number of injection booths from ten to six and prioritizing only frontline services. So far, he said, he hasn’t seen a major change in the number of clients.
For Mary, there’s also a sense that the current pandemic situation is simply adding another — albeit concerning — layer on top of ongoing public health crises people who use drugs have faced for years.
“We’ve got an epidemic of overdoses, so working in a pandemic situation for us is actually the norm,” he said, citing years of hepatitis C and HIV epidemics. “We’re already used to that. Working with people who have low immunity or no immunity at all is the norm for us as well.”
But new challenges are looming at supervised consumption sites because of COVID-19, such as a shortage of hand sanitizers. And with weeks-long mandated reductions or closures of services, frontline workers are concerned about how the situation is evolving for people who use drugs.
“I feel like some of the overdose crisis stuff is going to spike even more because the services that exist are being modified and reduced in capacity,” Ko said.
“We’re only in the early stages of being hard, it’s going to get much harder for people if we have to stay in this sort of mode for any length of time or if it gets more restricted.”
Safe supply needed
Frontline workers have also raised concerns about what happens if people who use drugs are forced into withdrawal or have trouble accessing medications such as methadone or prescription heroin — forms of opioid agonist treatment (OAT) that can help people who use opioids.
“During the epidemic, I would say supply is even more crucial because I think no supply of drugs means there are going to be some people who are going to be withdrawing,” said Mary. “That’s really tricky and dangerous.”
For Shaver, this is the reason she stressed the importance of continuing meetings for the BC Association of People on Methadone, a group within VANDU of which she is the president.
“All the people that attend are OAT consumers and we need to make sure that we are all very connected to the things that are happening so that people will be able to get their prescription because that would be really awful if communication isn’t open,” she said.
Shaver added that the group is in regular contact with provincial and federal governments to advocate for easier access to OAT during social distancing. And they are seeing results.
According to a March 14 memo, Health Canada has been planning exemptions to ease access to and extend prescriptions for controlled substances such as OAT.
“We expect to issue these class exemptions during the week of March 16, 2020,” reads the memo.
Health Canada said in an email to Ricochet that these exemptions are set to last until September 30, adding that the directive doesn’t allow pharmacists to “initiate a new medical treatment with controlled substances.”
“Legislative or regulatory changes may be required in some provinces and territories to put in place these new activities for pharmacists and nurse practitioners,” said the email. “Health Canada recommends contacting your pharmacist or provincial regulatory authority to check when and if these activities are available in your area.”
The province of B.C. announced on March 16 that pharmacies can provide refills of prescriptions or an “emergency supply” if needed, without needing an updated prescription from a physician.
The College of Pharmacists of BC confirmed to Ricochet that this mandate includes controlled substances such as OAT. It also noted that this works alongside another new change that eases access. Pharmacists can now decide on their own to deliver the medications to patients, a measure originally scheduled to take effect on April 1 but moved up given current conditions.
The pace of change has been slower in Quebec and Ontario.
The Quebec Order of Pharmacists announced on March 16 that it is giving pharmacists more flexibility and allowing for prescription extensions. When asked if this applies to controlled substances such as OAT, the body said in a March 19 email to Ricochet that “it is awaiting instructions from Health Canada on this subject.”
The Ontario College of Pharmacists announced on March 20 that the exemptions listed under the Health Canada memo still need to be adapted into provincial regulations. “The College is quickly moving forward with developing regulatory amendments to relevant provincial legislation,” which would then go to the ministry for approval, it stated in a press release.
But frontline workers are looking for a long-term solution and reiterating their call for safe supply programs — something that they and drug-use activists have long pushed for.
“It would have been much easier and safer if the government actually had a safe supply program,” Shaver said, adding that she has heard from others that there’s now also difficulty in getting illicit substances. “Not only are we going through a fentanyl crisis now, we have a deadly virus crisis ... so there’s like a double whammy everywhere.”
“It would be the perfect time to ramp up all the safe supply programs,” said Ko. “They should take safe supply seriously now, don’t wait.”
An interconnected challenge
And for all the frontline workers, there is one common message: the pandemic is putting the socioeconomic challenges faced by people who use drugs in sharper focus.
“We’re dealing with a very, very vulnerable population — many with mental health issues, physical health issues, seniors, people with disabilities,” said Blyth, “so it’s just really challenging.”
There is also a big overlap between people who use drugs and the housing-insecure population. This can pose challenges to the need for self-isolation or even basic hand-washing guidelines, as pointed out in a March 17 petition created by Vancouver’s Carnegie Community Action Project that has garnered over 10,000 signatures.
“We got to be proactive on this because even at Oppenheimer Park where it’s the tent city, there’s barely even proper access to water,” Shaver said.
“If they’re not even able to have proper water and soap to wash their hands, how the heck are they supposed to help stop this if it were to come?”
Since then, Vancouver Mayor Kennedy Stewart has announced that the city is adding 11 more hand-washing stations in the Downtown Eastside, the neighbourhood that encompasses Oppenheimer Park. The city is also working to secure locations that could be used for housing-insecure individuals’ self-isolation and with community partners to maintain essential services, while also urging the province to put in place an eviction ban.
B.C. has now banned evictions of those who are unable to pay rent in BC Housing–funded buildings, while also working to develop “isolation protocols” for those who are housing insecure or experiencing homelessness.
Meanwhile, Quebec and Ontario have already put in measures to halt most or all evictions, respectively.
The federal government is also putting $157.5 million from the $82-billion package announced on March 18 towards its Reaching Home program to support individuals experiencing homelessness.
Beyond this larger challenge, supervised consumption sites are also operating as critical information centres, especially as access to a phone or TV isn’t a given for many of the people they serve.
Looking ahead at the weeks of social distancing to come, frontline workers are determined to maintain their services in some shape or form, even if their sites have to close.
“We’d have to work on something extra,” Shaver said.
“We’ll get the street crew out there or something will happen. We’re not going to leave anybody high and dry, whether we’re going to be closed down or not. We would rather ask for forgiveness than permission.”
They are also stressing the need to continue thinking about and supporting people who use drugs from one public health crisis to the next.
“This is a challenging time for marginalized folks, but I will offer that they’re always navigating through and living resiliently with their own challenging circumstances,” Lester said.
“When I think about the trajectory of HIV and AIDS in the work we’ve done in the history of organization, that’s always been how things have been and that’s what social justice efforts are: to raise the voice of the marginalized, try to bring a more equitable system in place, a social service system to make sure the most marginalized are taken care of.”