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Marginalised drug users are among the most vulnerable when it comes to the risk of infections due to their low social status, lack of strong social networks, poor general health condition and low access to public health care. The lockdown and “social isolation” policies have devastating consequences to this group, leading to loss of income, loss of housing/shelter and loss of access to basic goods (running water, food, medicines etc.) and services (shelters, HIV and HCV testing, counselling and treatment, harm reduction equipment). Arrest and incarceration carry specific risks. These risks are exponentially higher in cities with repressive drug policies, with no support for harm reduction programs. This article gives a short overview about how European cities responded to the crisis, based on the assessment conducted by Drugreporter, the drug policy website of the Rights Reporter Foundation (RRF).  

The impact of the crisis on people who use drugs

Many factors shape how people use drugs and how vulnerable they are to risks, including gender, social status, race and age. Social inequalities and systemic discrimination are key factors behind drug-related death and suffering. Although there are several elements of the current crisis that affects all drug users regardless of social status, it hits those people the hardest who lived in poverty, without stable housing, with untreated childhood trauma and/or psychiatric conditions even before the crisis. For them, the pre-crisis situation was far from “normal” – we can only speak about the escalation of a pre-existing crisis. And for well-integrated people who use drugs the crisis could lead to loss of social security and health and thus, result in riskier drug use behaviour.

It will take some time to assess the social and health impact of the COVID-19 epidemic on drug markets and drug use trends but we can highlight some basic risk factors and trends, based on the reports of harm reduction service providers. Some of these factors were related to the direct risks of COVID-19 infections but most can be linked to the safety and lockdown measures introduced by government to tackle the epidemic. These measures disproportionally affected the marginalised groups of society, effectively cutting off their vital connection points with the mainstream society and economy.    

Loss of income
People who use drugs often live on the margins of society & make a living from begging, sex work, or other unstable jobs that have mostly disappeared due to the lockdown. Several big European cities that thrived from mass tourism became now ghost towns with no job opportunities for those people who lived from the informal economy based on tourists. With the closure of stores, restaurants and shopping malls, many people who live on the street lost the only places where they could have accessed some food and water, as well as to recharge the cell phones, to be connected to their loved ones.

Loss of services
Many day-care centres, drop-ins, and other services have closed down due to the lockdown measures. These were the places where people could have accessed basic support, HIV testing, and counselling, showers, washing machines, etc. Online services are often not accessible for them: even if they have a cell phone, Internet connection and opportunities to recharge are scarce. The crisis means increasing isolation for many people who are dependent on public services to survive.

Risk of incarceration
Prisons and jails are overcrowded in many countries and have poor hygienic and health conditions, with no access to health care. While we see many efforts from other parts of the world to introduce early release measures for non-violent offenders, we don’t see that happening in Europe. During the epidemic, to be incarcerated in overcrowded cells makes you very vulnerable to contract the virus – and prison health services are not prepared to deal with mass outbreaks. Not to mention to deal with drug use within prisons: harm reduction services often miss completely from most prisons.

Difficulty to deal with confinement
Those who have homes and can self-isolate have difficulty dealing with the psychological effects of long-term confinement. Loneliness, anxiety, and domestic violence can lead to crisis situations. Some people may think a quarantine is a good time to try some psychedelics – and it may be for some people but for others it is not. We should remember that drug use as an experience is always shaped by three things: set (our psychological and physiological condition), setting (how we feel in the environment and with the people in it) and dose (how much drugs we use). These should be carefully prepared, including the day after, which can be difficult for some people if they are not able to rest in a relaxing environment and don’t have time to integrate their experiences.

Loss of housing
Many people who had unstable housing have lost their homes due to the economic slowdown, whilst others who had stable housing cannot afford to pay rent and face eviction. Many governments introduced now moratorium on evictions, which is a positive sign – but still, paying the rent and bills in the end of the month is a serious challenge for many, who are forced to break the quarantine to be able to survive.

Growing drug prices & shifting markets
It is still not clear how and if the crisis will have a long-term impact on illicit drug markets but the disruption of trafficking routes and drug production are reported from several countries. Some drugs are getting more expensive at the same time as the people who use them have less income. We hear reports about new substances replacing others, further increasing the risks – because it is always riskier to use unknown substances.

Poor withdrawal management
People with no access to drugs can go through withdrawals during the lockdown when the health care system is overburdened. Detox and residential centres may stop new admissions, leading to life threatening events. It is important to know when people experience symptoms like tremors, seizures, vomiting or suicidal thoughts, they should not shy away from seeking medical help, even during the COVID-19 epidemic.

Barriers to access to opiate substitution treatment
There is a risk of using mass transportation to access drugs. In most countries, a longer take-home period for OST programs was introduced, which helps clients to reduce physical contacts with health workers. However, many people with drug dependence need support to deal with economising their medicines for a longer period. In the long run, this crisis can be beneficial too in breaking down the barriers to access OST – so the less restrictive rules should be upheld even after the crisis.

Disruption of medical treatment
Because of the overwhelmed public health system it has become difficult to ensure the continuity of life-saving medical treatment (such as ARV). If the crisis lasts longer, there will be shortages in life-saving medications.

Lack of personal protective equipment (PPE)
Although many marginalised people have chronic health problems, including respiratory diseases, they rarely have access to PPE, such as disposable masks, gloves, or basic hygienic tools to sanitise their hands. People who use drugs should be very cautious when purchasing and using drugs: minimising physical contacts with their dealers and other drug users, avoid sharing their drug paraphernalia and clean/disinfect everything they buy.

Overcrowding at shelters
Overcrowding at the night shelters is a significant health risk for both clients and staff. There are often no resources to ensure physical distancing and safety measures. It is a great challenge to maintain quarantine measures at a shelter with clients who use drugs if they do not have access to legal substitution of illegal drugs.

Urban harm reduction responses to the COVID-19 crisis

Civil society organisations were the first to respond to the crisis in regard to harm reduction, in both local/national and regional/international level. The Correlation European Harm Reduction Network and the Eurasian Harm Reduction Association, in collaboration with the Rights Reporter Foundation, published a joint position on the continuity of harm reduction services during the COVID-19 crisis on March 19. This position paper included 12 recommendations to policy makers and service providers, highlighting the need for the continuity of harm reduction services and for safety measures to prevent COVID-19 infections.

  1. Ensure the continuity and sustainability of harm reduction.
    2. Provide adequate funding and PPE for harm reduction services.
    3. Acknowledge harm reduction services as critical interventions.
    4. Develop specific guidelines and regulations for harm reduction services.
    5. Longer take-home period for OST and HAT.
    6. NSP should provide PWUDs with larger amounts of injecting equipment.
    7. Harm reduction services should provide COVID-19 prevention material and information.
    8. Safety measures and avoidance of overcrowding at drop-in services, day shelters, and DCRs.
    9. The health situation of PWUDs should be monitored closely.
    10. Night shelters need to be made available for people experiencing homelessness.
    11. Group-related services, such as meetings and consultations, should be cancelled and postponed until further notice or organised as online services.
    12. Harm reduction services should establish a safe working environment.

Drugreporter, the drug policy website of the Rights Reporter Foundation, has been monitoring the implementation of these recommendations, based on reports received from service providers and activists from European cities. We cooperated with the staff of DUnews, a Russian language video blog, hosted by the Drugreporter, who were responsible for gaining information from Russian speaking communities. We approached professionals and activists directly and asked them to provide us updates about 1) how the COVID-19 epidemic affects people who use drugs and 2) how harm reduction services respond to this crisis. From early March, we published reports from more than 30 European cities.

In addition to the written reports, we launched Stories from the Frontlines, a live video series of discussions with professionals and activists working in the frontlines of harm reduction (from ten countries until June 3 2020). Our regularly updated info page is a resource of information for anyone who would like to compare the situation in different European cities with regard to what measures were introduced by governments and what initiatives were launched by civil society organisations.

Opiate Substitution Treatment
In most cities OST programs have been continued during the lockdown measures (with the exception of Moscow, where OST is illegal) but their regulations significantly changed. Many service providers reported that restrictive rules, such as the requirement of showing up personally at treatment sites, have been abolished and longer take-home periods were established (ranging from 3 days to 2 weeks). However, in some cities, institutional OST service providers showed some reluctance to ease these restrictive rules and daily visit to the clinics remained the rule in some cities (for example in Poland and in Ukraine). Some professionals reported that new admissions were suspended during the lockdown (for example in Ukraine). In cities where organised communities of people who used drugs exist, they played a significant role in breaking down these barriers more effectively. For example, in Germany, where JES, the German network of people who used drugs published its call for easing the rules in mid-March. Or in Georgia, where the state allowed to extend the take-home period for 5 days, due to the timely advocacy efforts of PWUD organisations. OST clinics also introduced safety measures, such as mandatory hand sanitizing at entry and one-by-one client consultation. In Norway the community of people who use drugs, in co-operation with the Ministry of Health, decided to introduce stimulant substitution programs for homeless people.

Information, flyers, online consultation
Most therapeutic sessions, individual and/or group consultations were moved online in most cities. A significant barrier to access online support is the lack of access to computers and Internet connection, or electricity to recharge phones. To bridge this gap, street phone recharging posts were placed in Barcelona to help homeless people to recharge their cell phones. Several organisations produced specific posters and flyers for the most affected communities. The harm reduction poster for PWUDs on COVID-19 was translated to several languages and distributed widely among community organisations. In Barcelona, Energy Control produced informational videos for party going young people. David Stuart wrote a flyer for participants of the chemsex scene. Metzenires, a Barcelona based NGO, produced a flyer for women who use drugs. In Ukraine a national hotline was established for people who use drugs on OST and drug treatment.

Drop-in centres, NSPs and DCRs
In most cities, drop-in centres and drug consumption rooms continued to be open after the introduction of lockdown measures in most cities – with safety regulations in place. For example, only one client could enter at a time, hand sanitizing at the entrance, mandatory masks for the staff and crew. Some service providers moved services outdoor, in front of the drop-in centre (e.g. Bratislava), or limited encounters with clients to give out packages through the window (e.g. Krakow). Beside PPE, harm reduction programs distributed food, water and other essential tools (e.g. masks, gloves, soaps etc.) to survive harsh life on the street during the lockdown. Most service providers gave out larger number of needles and syringes to minimise physical contacts. Several services reported special survival kits (including tampons and other hygienic tools) distributed among women who use drugs. Drug consumption rooms closed down their chill out areas and community spaces and limited the number of those who could be inside. In Zurich it was reported that the drug consumption room was moved outdoor, into a tent, where all relevant services could be accessed. As the fixed sites were closed or limited, the significance mobile outreach programs have increased. A new mobile outreach program was opened as a response to the epidemic in Budapest (HepaGo). In Athens an outreach point was created in the centre of the city where people could access harm reduction equipment. Some efforts were reported to monitor the COVID-19 situation among homeless people. In Copenhagen for instance, a targeted peer-led mobile outreach initiative tested drug users and sex workers on the street for COVID-19. In most services there was no access to COVID-19 tests in adequate number to start massive screening programs, only antibody tests for social and health workers. 

Shelters for homeless people
Several cities open up new spaces to ease overcrowding and shelter homeless people in a humane environment. Some of these shelters were especially accommodated to accept people who use drugs. For example, special shelters for homeless people who use drugs were opened in Barcelona, with a drug consumption facility. Open air shelters (camps) were also reported (e.g. Prauge). The mayor of Athens opened a special shelter for people who use drugs, which was linked with drug treatment centres, including OST. Most of these special shelters provided access to medications to substitute street drugs and thus, enable clients to stay in quarantine. Service providers from Amsterdam reported that due to expanded shelters spaces they experienced a significant reduction in interpersonal conflicts and an increase of the wellbeing of clients during the crisis, compared to the previous period. Political resistance to open new shelter spaces was reported from Budapest, where the ruling government party launched a campaign against a new shelter but the opposition mayor of the city sheltered homeless people at the city hall instead.

Factors facilitating effective urban response to the COVID-19 crisis

Based on Drugreporter’s assessment of the reports received from European cities, we can conclude that the COVID-19 epidemic and the measures to control it did not only create a crisis, which affected the most vulnerable groups of society disproportionally. For most harm reduction services, this crisis has been just another, new episode of a permanent crisis, a struggle for survival, that started in 2008 with the financial crisis and austerity policies. Many service providers emphasized that they do not wish to return to the pre-crisis “normal”, because they did not consider it a normal situation.

The crisis opened up the opportunities for new, innovative solutions. Outdated rules and barriers have been broken down and, in some cases, new forms of harm reduction have been explored. Harm reduction as a movement proved to be a flexible and strong framework to adapt to new circumstances and empower communities to survive the crisis. However, the upcoming economic crisis, especially if it comes with a new wave of austerity measures, can endanger those new innovations and achievement in the longer run.

identify some factors that played a central role in strengthening/facilitating and/or weakening/distracting urban harm reduction responses to the COVID-19 crisis.

1. Drug laws/law enforcement
Where the criminalisation of people who use drugs was not enacted/enforced, and law enforcement authorities do not focus on arresting and prosecuting small scale drug offenders, PLWUDs had more opportunities to maintain the health and well-being by connecting to social and health services. Criminalisation pushes people to the margins of society, fear of arrest prevents people from being visible and accessible for service providers. Some cities reported that the police continued stop-and-search practices and this was not only a barrier to access services but exposed people to direct risk of COVID-19 infections.

2. Meaningful involvement of civil society
Civil society organisations, including professional service providers and community advocacy groups, played a key role in crisis prevention efforts. Unlike many state and government actors, they responded to the changing environment with significant flexibility and speed. They refocused their efforts, reallocated their resources and reshaped their services according to the new needs of their clients. In cities where these organisations are involved in local/national decision making in a meaningful way, they had a significant impact on changing rules of state-run services and policies. The COVID-19 epidemic revealed the inherent value of civil society involvement in formulating timely and effective government responses in crisis situations. We should especially highlight the importance of the involvement of the affected communities in this regard.

3. Access to harm reduction
Austerity politics had a severe impact on harm reduction services in most European cities where we received reports from harm reduction professionals and activists. Where harm reduction services had to be closed down or limited due to budget cuts or political attacks, the communities of people who use drugs, with their special vulnerabilities and needs, remained invisible for policy makers and health institutions. In cities where there was high access to harm reduction before the crisis, the response to COVID-19 crisis among the most vulnerable communities was perceived to be more effective. They could accommodate the needs of people who use drugs in a much more effective way at other social services (e.g. homeless shelters) and health care services (e.g. hospitals).