COVID-19 has revealed a lot of inequities. For people that are homeless, it has shown how lack of housing puts people’s health and safety at risk due to inability to enact prevention measures. Handwashing and housing are basic protections against COVID-19 and in themselves, harm reduction interventions. In Canada, almost 80% of Canadians use some type of substance. For people in low income neighbourhoods, the rate of harms (not necessarily the rate of use) is often higher than the general population.
COVID-19 is escalating substance use related harms particularly for people who are homeless or at risk of homelessness and living in poverty. People are at increased risk for more serious COVID-19 symptoms and complications. Alcohol use can increase susceptibility to respiratory problems along with weakened immune systems due to high levels of alcohol use. Smoking or inhaling substances can increase respiratory problems and opioid withdrawal will also worsen breathing.
Many individuals, already living in poverty, are experiencing a loss of income from panhandling and recycling. Illicit drugs are becoming more expensive and more toxic. Liquor stores may have limited hours and may not be accepting cash. Further, there are changes in locations, hours, and closures of harm reduction services such as supervised consumption sites, reducing access to life saving services.
Withdrawal and treatment services are less available due to COVID-19 restrictions. Public health messages to stay at home conflict with public health messages to not use alone. The result is that individuals who use illicit drugs are at increased risk of overdoses, bloodborne diseases and other harms. For those who use alcohol, there are increased risks of withdrawal, non-beverage use or substitution of illicit drugs when beverage alcohol is not available and unaffordable.
Why employ harm reduction strategies in housing and shelters?
First, at any time not just during COVID-19, harm reduction approaches can prevent substance use related harms like HIV/Hep C, overdoses, manage withdrawal, and reduce harms like stigma. During COVID-19, implementing harm reduction strategies can help people to physically distance, shelter in place, stay at home and self-isolate.
Harm reduction is a pragmatic approach that accepts that drug use is a reality in society and that people regardless of their choice to use or not use substances should be respected and treated with dignity and compassion. A harm reduction approach facilitates access to services and supports because providers accept people ‘where they are at’ rather than requiring sobriety or abstinence first. Further, people who use substances should be engaged and meaningfully participate in decisions that affect their lives. Harm reduction is a key principle of Housing First along with consumer choice. Harm Reduction International outlines key values and principles of a harm reduction approach. There is a well-established evidence base for many harm reduction interventions (e.g. clean supplies, supervised consumption sites and more).
What harm reduction strategies and practices could be employed in housing and shelters during COVID-19 and beyond?
Peer2Peer networks are essential for health promotion, to prevent harms of use and delivery of accessible and effective harm reduction interventions in housing and shelters. Engagement and effective participation of people with lived experience means effective policies and programs that work. For example, the P2P Project identified, implementated and evaluated interventions determined to be valuable to people who use drugs. Peer education, advocacy and support is even more important during COVID-19 to prevent substance use harms like overdose and isolation.
Safer Use Equipment
Clean supplies remain important to prevent bloodborne disease and overdoses. Ensure a supply of pre-packaged safer inhalation kits, safer injection kits and safer sex supplies and Naloxone kits available upon request without limits on quantities. Sometimes people do not feel safe to ask for themselves so they may be asking for others. Peer workers play a very important role in housing and shelters to distribute supplies in a safe and supportive way.
Safer Use Education
When we are encouraging people to physically distance, stay at home and self-isolate, safer use education is more important than ever! There are many resources out there to help with this. Look to your local public health unit or organizations of people who use drugs for resources that have been created to address harms of illicit drugs use. For illicit drug use, see COVID-19 harm reduction guidance. For alcohol, provide COVID-19 safer drinking tips.
Safer Organizational Policies
Harm Reduction is more than needles. Organizations should have both substance use and harm reduction policies that are in alignment with harm reduction principles and best practices. If your goals and philosophy are aiming for harm reduction, avoid policies that prohibit substance use on site. Instead think about strategies for creating safer spaces such as peer witnessing or overdose prevention sites. Every organization needs a harm reduction policy that gives staff clear direction on what the organization supports. Policies and practices should not contradict each other. For example, giving clean supplies but prohibiting use onsite or banning people for use.
With COVID-19, there are a lot of changes and considerations related to providing overdose responses for first responders. Check local public health advice as to use of masks, cleaning procedures, and other resources during COVID-19 as jurisdictions have slightly different recommendations. Consider implementing managed alcohol to provide a safer space for ‘sheltering in place’ as well as to prevent harms of withdrawal and high-risk drinking.
Given the toxic drug market, there has long been a need to mitigate the risks associated with accessing a poisoned drug market. COVID-19 has only increased the need for alternatives and a safe supply. Encourage and support referrals to opioid agonist programs as well as support individuals to access safer supply programs where available. Look for and engage physicians who are willing and familiar with such options. See BCCSU Risk Mitigation During Dual Public Health Emergencies for further guidance.
This is an overview of harm reduction interventions which can prevent the harms of substance use and save lives during COVID-19 and beyond. What blocks our ability to implement harm reduction? It can be funding or policies, but more often than not it is attitudes that tend to blame or criminalize people for substance use that are rooted in current drug policies that prohibit use as well as myths, misinformation and misunderstandings of the causes and consequences of substance use.