What you need to know
The COVID-19 pandemic has negatively affected people who use drugs through major disruptions in substance supply and increased risk of relapses and overdoses. There has been a decrease in potency and availability, substitution for toxic and tampered substances, and increases in use, prices of substances, risky use behaviors such as using alone and at home more often, and sharing and re-using substance supplies, such as injection equipment. Future health policy and pandemic planning efforts to include improved supports and services, accessibility of safe supply programs, take home naloxone kits, and novel approaches to ensure people who use drugs have the tools necessary to mitigate these elevated risks when using substances.
What is this research about?
The COVID-19 pandemic and public health measures put in place to reduce spread of the virus have affected people who use illicit drugs to a greater extent than the rest of the population. For example, the closing of businesses and borders as well as bans on non-essential travel affected the drug supply around the world. Also, people who use drugs may be at greater risk of COVID-19 and negative outcomes because they tend to have chronic conditions such as HIV, hepatitis and chronic obstructive pulmonary disease.
There is no COVID-19 research looking at the experiences and opinions of people who use drugs, and no research specifically focused on Canada. The current study looked at how COVID-19 affected substance use and the supply of drugs in Canada from the perspective of people who use drugs.
What did the researchers do?
Researchers conducted telephone interviews with 200 adults who use drugs who are current residents of Canada, fluent in English or French, using a psychoactive substance at least once a week and/or currently receiving opioid agonist therapy treatment.
The telephone interview guide, developed in consultation with peer advisors, asked about the changes to substance use frequency, substance use characteristics, substance supply and the needs and challenges of people who use drugs during the pandemic. Interviews took place between May 4, 2020, and July 27, 2020, with at least 30 people from each of the four regional Nodes from the Canadian Research Initiative in Substance Misuse (CRISM) network.
What did the researchers find?
Participants were an average age of 41 years and more than half were male. About 60% were Caucasian and 30% were Indigenous. Just over a third of participants were on opioid agonist therapy.
The most commonly used psychoactive drugs were stimulants, such as cocaine, crack-cocaine and amphetamines, including methamphetamine/crystal meth. Opioids were the next most common type of drug used, followed by cannabis, alcohol, benzodiazepines, and lastly, hallucinogens. Polysubstance use (simultaneous use of two or more types of drugs) was very common.
Quality and potency
Participants indicated drugs were of poorer quality and less potent, and the supply was heavily altered with unknown ingredients including fentanyl. This often affected their tolerance levels, which led to withdrawal symptoms that were more frequent and more immediate than usual, as well as increased risk of having irreversible and/or potentially fatal overdose.
Many said prices had increased dramatically since COVID-19. Some had to substitute their drug of choice for a more affordable, often contaminated, substitute.
Availability or accessibility
Three quarters of participants said there were changes in the drug supply. Of these, six out of 10 said drugs were more difficult to find, which meant they had to opt for poorer quality drugs and higher cost. This meant people had to wait longer to access their drug of choice, travel farther, change their supplier, or change how/where they interacted with their usual supplier.
This lack of supply led to more withdrawal symptoms or having to spend more time searching for quality drugs, which increased the risk of getting COVID-19. Some also had to substitute for whatever was available, including potentially contaminated drugs, or opting to consume licit drugs, such as alcohol, due to ease of access and availability
Increased substance use
Almost all participants (98%) said COVID-19 changed how frequently they used drugs and half said they used them more often than before the pandemic. The most common reasons were loss of their job, fear of catching the virus and elevated mental health concerns (e.g., stress, anxiety, boredom).
Some said they used drugs more often to help them cope with the negative physical, mental and social impacts of the pandemic. Some said they used more often to help them manage pain or difficulty sleeping because they could not access pain relief or withdrawal services.
In areas where the drug supply was greatly affected, participants said they often bought more drugs at any one time because they were unsure when they would be able to buy more, which often led to increased use. Some said they used more at any one time because the quality of the drug supply had decreased and they needed a higher dose to achieve the same effect.
Among those who said their drug use had changed, 7% had relapsed during the pandemic. Reasons for this included stress related to COVID-19, including losing a sense of stability as a result of a loss of employment, of their daily routine, and of their social and substance use support, as well as a result of the negative mental and physical effects of the pandemic.
Risky drug use behaviours
Many indicated that they were more likely to use drugs alone and at home. Participants also reported reusing or sharing paraphernalia (e.g. syringes or pipes and smoking stems). Of these, nearly half said this was something they had only done due to the pandemic and the reduced capacity of harm reduction services and/or needle exchange programs that typically provided supplies.
Of those who discussed their perceived overdose risk, nine out of 10 said their level of risk had increased, which was mainly due to supply-related issues, such as an increasingly contaminated and toxic substance supply and fluctuations in availability. This often led participants to substitute for other substances or use inconsistently, which also affected their tolerance levels. The social isolation and increases in using when by themselves also made them feel especially vulnerable.
Decreased substance use
Four out of 10 participants indicated using less substances since the start of the pandemic. Reasons included not wanting to go out in public, no longer having access to places to obtain and use substances, no longer being financially able to support their use, decreased quality and increased prices, and limiting social interactions to avoid contracting the virus, which was especially common among immunocompromised individuals.
How can you use this research?
This study highlights an important link between the supply of illicit drugs and health harms, such as drug poisoning, overdose risk, and unsupported withdrawals. This research may be useful to policymakers and program planners and decision-makers wishing to develop and implement policies and programs to enhance the accessibility of a safe supply, sterile paraphernalia, take-home naloxone and drug-testing kits, as well as novel approaches to help ensure that people who use drugs have the necessary tools available to make informed choices and mitigate risk. There should also be increased access to innovate and evidence-based harm reduction services such as telemedicine and other critical mental health and support services, including toll-free numbers to access substance use supports.
About the researchers
Farihah Ali1, Cayley Russell1, Frishta Nafeh1, Jürgen Rehm1, 2, 3, 4, 5, 6, 7 , Sean LeBlanc8, 9 , Tara Elton-Marshall1, 2, 3, 10, 11
- Institute for Mental Health Policy Research, Centre for Addiction and Mental Health (CAMH), Toronto, Canada
- Dalla Lana School of Public Health, University of Toronto, Toronto, Canada
- Campbell Family Mental Health Research Institute, CAMH, Toronto, Canada
- Department of Psychiatry, University of Toronto, Toronto, Canada
- Institute of Medical Science (IMS), University of Toronto, Toronto, Canada
- Institut für Klinische Psychologie und Psychotherapie, Technische Universität Dresden, Dresden, Germany
- Department of International Health Projects, Institute for Leadership and Health Management, I.M. Sechenov First Moscow State Medical University, Moscow, Russia
- Drug Users Advocacy League, Ottawa, Canada
- Canadian Association of People who Use Drugs (CAPUD), Ontario, Canada
- Department of Epidemiology and Biostatistics, Schulich School of Medicine and Dentistry, Western University, London, Canada
- Department of Health Sciences, Lakehead University, Thunder Bay, Canada