The drug supply is chaotic. Social structures are weakening. Stress and uncertainty are playing a role. Across the country, health centers, harm reduction groups, and other organizations serving people who use drugs are seeing increased numbers of participants. They’re hearing reports of increased overdoses, fatal and not.
And they’re responding, in part, by distributing more naloxone, a lifesaving drug that can quickly reverse an overdose, either of opiates like heroin or of synthetic opioids.
In June, Direct Relief sent out about 90,000 doses of naloxone – significantly more than during the early months of the pandemic – to organizations across the country, many of which requested higher numbers of naloxone doses than was usual.
“We’re definitely seeing an increase in need,” said Neann Wedgeworth, a prevention coordinator at the health center KC Care, in Kansas City, Missouri, which has a program focused on people who use drugs. “I’ve seen a lot of people who are either first time to our program or people who have had a reoccurrence of use.”
Before Covid-19, Wedgeworth said, the program saw approximately 35 participants a day. Now, that number is up to 45 – an increase she attributes to a loss of social services, employment, and support structures. Participants can receive harm reduction supplies, clothes, sack lunches, or hygiene kits – all of which, Wedgeworth said, are needed.
What’s Changing and What’s Known
Fatal overdoses are on the rise in the United States. The New York Times reported in July that drug deaths had risen an average of 13% from 2019 to 2020, according to an analysis conducted by the newspaper.
But when it comes to tracing nonfatal overdoses and increased drug use, it’s harder to pull a clear picture together, said Rachel Winograd, a research professor at the Missouri Institute of Mental Health.
While fatal overdoses are more easily tracked through government records, information on drug use and nonfatal overdoses is generally gathered through less-reliable voluntary reporting – and that’s at the best of times.
“‘Research’ in quotes, and data collection, is everybody’s last priority right now,” she said. “Sometimes I feel like [researchers] are among the last to know what’s happening there.”
But drawing from on-the-ground sources, Winograd had several major insights.
For one thing, social services, such as inpatient facilities and behavioral health interventions, are less available, Winograd said, which puts more responsibility on the shoulders of organizations still offering services.
And more informal social supports have also weakened, thanks to shelter-in-place requirements and social distancing. “People who use drugs have always stuck together and looked out for each other,” Winograd said. Now, “the general theme that we’re hearing is that people are not gathering in groups and using in public places as much as they would have.”
And finally, breakdowns in the global drug supply chain, which have made it harder to both import the raw materials used to make synthetic drugs and to export drugs via traditional channels, have significantly altered the drug supply.
“The drug supply is very unstable and unpredictable, and whenever you have that, there’s chaos and there’s overdose, because you don’t know what you’re getting,” Winograd said.
Even the upheaval caused by losing one’s job or housing can have an impact on drug use, Winograd said. Move to a different location, and you have “a different drug dealer as well, whom you don’t know, who doesn’t know you. You don’t know how they mix their drugs,” Winograd said. “There’s not a shared understanding and loyalty there.”
On the Ground
Organizations around the country are seeing these effects on the ground, in real time.
Mark Kinzly’s group, Texas Overdose Naloxone Initiative, has seen a significant increase in the need for naloxone over the past few months.
“The reason there’s an increased need for us is many of the service providers have stopped providing service,” said Kinzly, who calls himself a “streetologist.” “We’ve increased our visibility and delivery of services, because this is something that’s going to kill a lot of people.”
But Kinzly has also noticed an increase in drug use in his community.
He explained that, while the public often imagines drug use in its most extreme and debilitating form, “the majority of people who use drugs fall in the middle…Their drug use usually is not affecting other areas of their lives.”
But a loss of employment or similar stress can cause someone to use more intensively, he said, increasing the need for intervention.
Nadia Eskildsen, a prevention coordinator at the health center CrescentCare in New Orleans, has seen similar stress in her program’s participants. “We know that all of these psychosocial issues affect people’s drug use,” she said.
Eskildsen said that, at the beginning of the pandemic, some other programs offering harm reduction services scaled back or temporarily stopped operations, driving more people to CrescentCare. “Not only were we seeing an increase in usage of our own clients, but we also saw so many new folks,” she recalled.
However, even as other harm reduction programs came back online, “the numbers we have seen have not changed, and are in fact starting to slowly increase weekly,” Eskildsen said.
In March, as the pandemic was gaining ground, CrescentCare saw approximately 200-250 patients a week seeking harm reduction services. Now, that number is in the mid-300s, according to Eskildsen.
At Choice Health Network in Chattanooga, Tennessee, Lesly-Marie Buer has noticed that changes to the drug supply have led to increased concerns among participants.
For one thing, said Buer, the organization’s research director, some people are moving from one drug to another based on what’s available. “When folks switch from using one drug that they’re really used to to another that they’re not used to doing, overdoses tend to increase,” she said.
In addition, Buer said, even people who use stimulants such as methamphetamine are now feeling the need for naloxone, as synthetic opiates show up in the stimulant supply.
The changing supply has actually had a greater impact on Choice Health’s participants than Covid-19 itself, Buer said. People are more nervous because “they feel like they don’t know the supply as well as they did previously.”
For Wedgeworth, “I knew when this started off, ‘People are going to lose access to things that keep them alive,’” she said. “It was devastating. I knew it was coming, but it was really devastating.”
Increasing Access
In collaboration with the pharmaceutical company Pfizer, Direct Relief has been working since 2017 to distribute 1 million doses of naloxone through its expanded Naloxone Access Program. In July, during the midst of the pandemic, the organization reached its million-dose mark – several months ahead of schedule.
Pfizer has contributed an additional 500,000 doses to Direct Relief, allowing the organization to aid groups serving people who use drugs to continue their vital work during the pandemic.
Direct Relief is also providing syringes, needles and alcohol swabs that were donated by the medical technology company BD.
