Controversy: Protecting People Who Use Drugs During COVID-19

hard drugs and alcohol, syringe, pills
hard drugs and alcohol, syringe, pills
Anna Lembke, MD, discusses how patients who use drugs are affected by the convergence of 2 public health emergencies – increasing overdose rates, and the COVID-19 pandemic – and addresses controversial solutions proposed by other investigators.

In marginalized populations, the coronavirus disease 2019 (COVID-19) pandemic has exacerbated pre-existing issues while presenting new challenges. Findings have indicated that COVID-19 has had a more pronounced negative impact on economic and work-related factors in women, racial and ethnic minorities, and low-income workers.1

For people who use drugs (PWUD), illicit drug use behaviors may become even riskier due to COVID-related circumstances, adding to the burden of infectious disease and overdose risk. A recent study demonstrated a surge in overdose-related cardiac arrest reported in a national emergency medical services database, with rates that have been roughly 50% higher during pandemic months compared to pre-pandemic rates.2 

Social distancing requirements may increase the likelihood of people using drugs alone, which is associated with an increased risk death due to an overdose. Meanwhile, tightened international border restrictions have increased the variability and potential toxicity of the illicit drug supply. In addition, there has been less access to harm reduction and addiction treatment services since the pandemic began.3

The convergence of these public health emergencies (increasing overdose rates, COVID-19) with the ongoing risk of HIV and hepatitis C virus infections among PWUD represents a growing syndemic, according to research published in the Journal of Studies on Alcohol and Drugs.3 A syndemic can “worsen or accelerate disease progression and social outcomes,” wrote Matthew Bonn of the Canadian Association of People Who Use Drugs in Nova Scotia and researchers from several Canadian universities.

While noting the need to scale up existing services, including syringe distribution services, take-home naloxone, and addiction treatment, study authors proposed that innovative approaches are needed to effectively prevent overdose deaths and infectious diseases in PWUD. They stated that the impact of the syndemic on PWUD could be reduced through the implementation of compassionate responses including decriminalization of personal drug use.

These steps would result in lower rates of medical complications compared to those associated with the criminalization of drug use, while also reducing stigma and increasing timely access to healthcare services including harm reduction services and substance abuse treatment. Such efforts may also reduce the risk of incarceration and help to prevent further spread of COVID-19 in correctional facilities.

Another suggested measure is the provision of a safe supply of pharmaceutical-grade drugs such as hydromorphone, diazepam, methylphenidate, and diacetylmorphine to PWUD. Pointing to the high rates of overdose deaths related to illicit fentanyl and fentanyl analogues, having “access to pharmaceutical-grade drugs would ensure that they are appropriately dosed and not adulterated, allowing PWUD to reduce their risk of unintentional overdose from a toxic illicit drug supply,” wrote Bonn et al. They discussed the need to address various barriers to decriminalization, including conflicts with standard provider prescribing practices.

“This pandemic is not only a public health crisis but also a chance to develop and maintain equitable and sustainable solutions to the harms associated with the criminalization of drug use,” the authors concluded.

For an additional perspective on the topic, we interviewed Anna Lembke, MD, associate professor and medical director of addiction medicine in the department of psychiatry and behavioral sciences at the Stanford University School of Medicine in California. Dr Lembke wrote a commentary on the paper by Bonn et al, which was published in the same journal issue.4

How are PWUD uniquely impacted by the COVID-19 pandemic? 

The pandemic and the deceleration of our global economy have interrupted the illicit drug supply, and to some extent even the licit drug supply. As a result, some PWUD are turning to new sources, not always reliable sources (for example, drugs laced with fentanyl) and, in some instances, new drugs. The unstable drug supply, combined with increased isolation and variable access to drug addiction treatment facilities, may be contributing to an increase in overdose deaths. 

Are you seeing evidence of the syndemic Bonn et al mentioned in their paper? 

I’ve had one patient die of a fentanyl overdose since the pandemic began. It’s hard to know if this would have occurred in the absence of the pandemic – it’s certainly possible. I’ve also seen an uptick in the number of people seeking treatment. This may be one of the pandemic’s silver linings. International data attest to a worldwide increase in people seeking treatment for addiction since the pandemic began.5

The bottom line is that it’s too early to tell what the full impact of COVID-19 will be on PWUD. Early reports of overdose deaths vary by geography, with some regions reporting increases in overall overdose deaths and others reporting decreases. As above, preliminary reports suggest an uptick in people seeking treatment for addiction. In other words, just as there have been winners and losers in the global economy since the pandemic, so too are we likely to see variable outcomes in people who use drugs. 

What are your thoughts about some of the solutions proposed by Bonn et al, such as scaling up existing services, temporarily decriminalizing illegal drugs, and providing a safe drug supply to counter some of the pandemic’s ramifications on PWUD? What other solutions do you see a need for? 

Even before the pandemic, we, as a country, needed to scale up existing addiction treatment services. Less than 1 in 10 persons with addiction has access to addiction treatment in the United States.6 Ironically, the pandemic increased access to addiction treatment overnight by allowing for the immediate deployment of telehealth services, thereby greatly increasing addiction treatment services to people living in rural, geographically remote, and underserved communities, which is another silver lining.

I suspect that even once the pandemic is over, telehealth will remain a mainstay of addiction treatment, which means we’re going to have to rethink the way we deliver services. One of the bigger challenges with telehealth is drug monitoring. Urine toxicology, for example, is an important part of ensuring a safe prescription drug supply. Since the pandemic began, doing regular urine toxicology screens has gone by the wayside. We need more telehealth-friendly ways of collecting biological samples for drug monitoring.

I disagree that decriminalizing illegal drugs and providing a so-called “safe supply,” even temporarily, is a solution to our drug addiction and COVID-19 pandemics. Decriminalizing hard drugs like cocaine, methamphetamine, and heroin will most certainly contribute to increased use and, with it, increased morbidity and death. Providing hard illegal drugs to PWUD in isolation will increase their risk of overdose death. Even now we continue to struggle with the misuse, addiction, and diversion of legal prescription opioids, a major contributor and the instigator of our current opioid epidemic. What we need instead is judicious and safe gatekeeping of prescription drugs, and a criminal justice system that incentivizes treatment among those who use illicit drugs.

What are recommendations for clinicians about how to support these patients in practice as well as advocate for them on a broader scale? 

Conceptualize addiction as an illness and help to destigmatize treatment. Realize that prescription opioids are as addictive as heroin. Avoid new starts and maintenance doses, except in rare, extreme, palliative cases. Engage in telehealth as a way to support our most isolated and marginalized patients.


1. Kantamneni N. The impact of the COVID-19 pandemic on marginalized populations in the United States: a research agenda. J Vocat Behav. 2020;119:103439. doi:10.1016/j.jvb.2020.103439

2. Friedman J, Beletsky L, Schriger DL. Overdose-related cardiac arrests observed by emergency medical services during the US COVID-19 epidemic. JAMA Psychiatry. Published online December 3, 2020. doi:10.1001/jamapsychiatry.2020.4218

3. Bonn M, Palayew A, Bartlett S, Brothers TD, Touesnard N, Tyndall M. Addressing the syndemic of HIV, hepatitis C, overdose, and COVID-19 among people who use drugs: the potential roles for decriminalization and safe supply. J Stud Alcohol Drugs. 2020;81(5):556-560. doi:10.15288/jsad.2020.81.556

4. Lembke A. Unsafe supply: why making controlled prescription drugs available for unsupervised use will not target the syndemic of HIV, hepatitis C, overdose, and COVID-19: a commentary on Bonn et al. J Stud Alcohol Drugs. 2020;81(5):564-565. doi:10.15288/jsad.2020.81.564

5. United Nations Office on Drugs and Crime (UNODC). Research brief: COVID-19 and the drug supply chain: from production and trafficking to use. Published May 7, 2020. Accessed online January 7, 2021.

6. US Department of Health and Human Services. Executive summary: Surgeon General’s report on Alcohol, Drugs, and Health. Accessed online January 7, 2021.

This article originally appeared on Infectious Disease Advisor