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Journal of Studies on Alcohol and Drugs logoLink to Journal of Studies on Alcohol and Drugs
. 2023 May 3;84(2):222–229. doi: 10.15288/jsad.21-00438

COVID-19–Related Changes to Drug-Selling Networks and Their Effects on People Who Use Illicit Opioids

David Frank a,,*, Noa Krawczyk b, Joshua Arshonsky c, Marie A Bragg c,,d, Sam R Friedman c, Amanda M Bunting e
PMCID: PMC10171252  PMID: 36971722

Abstract

Objective:

The COVID-19 pandemic has significantly affected people's ability to buy, sell, and obtain items that they use in their daily lives. It may have had a particularly negative effect on the ability of people who use illicit opioids to obtain them because the networks they relied on are illicit and not part of the formal economy. Our objective in this research was to examine if, and how, disruptions related to COVID-19 of illicit opioid markets have affected people who use illicit opioids.

Method:

We collected 300 posts—including replies to posts—related to the intersection of COVID-19 and opioid use from Reddit.com, a forum that has several discussion threads (i.e., subreddits) dedicated to opioids. We then coded posts from the two most popular opioid subreddits during the early pandemic period (March 5, 2020–May 13, 2020) using an inductive/deductive approach.

Results:

We found two themes related to active opioid use during the early pandemic: (a) changes in drug supply and difficulty obtaining opioids, and (b) buying less-trustworthy drugs from lesser-known sources.

Conclusions:

Our findings suggest that COVID-19 has created market conditions that place people who use opioids at risk of adverse outcomes, such as fatal overdose.

Covid-19 and the related preventative measures (e.g., social distancing, lockdowns) have created unique challenges for people who use illicit opioids. Many people who use opioids (PWUO) are physically dependent and must obtain them on a daily basis to avoid painful withdrawal symptoms (Best et al., 1999). This requires the maintenance of specific social and drug using/selling networks that may have been affected by COVID-19. Since such networks are illicit, they are particularly difficult to maintain, even before the added difficulties related to the pandemic.

COVID-19 also appeared at a time when drug-selling/ using networks were already experiencing a number of hardships (Alexander et al., 2020; Becker & Fiellin, 2020; Slavova et al., 2020). The continued proliferation of fentanyl and other adulterants in the illicit drug supply has not only dramatically increased rates of overdose among PWUO but also eroded trust and functionality within such networks as well (Carroll et al., 2020; Ciccarone, 2017). The emergence and growth of counterfeit prescription opioids has had a similarly chilling effect on the ability of drug-selling networks to deliver a reliable product (Green & Gilbert, 2016). Thus, additional changes in the quality and/or reliability of drug-selling networks resulting from the current pandemic could have significant effects on the lives and behavior of PWUO.

Although data on how COVID-19 has affected drug markets remain scant, limited research shows that COVID-19 has had a significant disruptive effect on drug supply networks (Bergeron et al., 2020; Smith, 2020; Walters et al., 2020). For example, a report by the Canadian Community Epidemiology Network on Drug Use highlights a number of converging issues including COVID-19, the disruption of supply chains, shutdown of overseas facilities, and disruption of drug shipping routes because of border closures that have made the illicit drug supply less stable (Canadian Centre on Substance Use and Addiction, 2020). Similarly, a qualitative study among Canadian persons who use drugs found that most individuals experienced supply disruptions leading to a decrease in drug availability and corresponding increase in risk behavior (Ali et al., 2021). Nearly half reported increasing their substance use as a result. Participants cited boredom, increasing amounts of time spent indoors and/or alone, and the negative “physical, mental and social impacts of COVID-19” as drivers of increased drug use.

A study of drug purchases on the dark web also uncovered significant disruptions. Researchers examining self-reported transactions found that although the rate of successful drug transactions between January 1, 2020, and March 21, 2020, was between 60% and 100%, after March 21, transactions with problems, including those never received, became the majority, and the rate of successful purchases dropped to a low of only 21% of all transactions (Bergeron et al., 2020).

Research also indicates that COVID-19 is linked to disruptions to the services that people who use illicit opioids use to moderate risk. For example, Bartholomew et al. (2020) found significant disruptions in syringe exchange programs that offer tailored social and medical services to people who inject drugs, including access to sterile and clean injection equipment, referrals to substance use treatment, HIV and hepatitis C testing, and overdose prevention (Bartholomew et al., 2020). Disruptions to services can make patients especially vulnerable to resuming illicit opioid use (Sun et al., 2020). Moreover, since people who use illicit opioids are a highly marginalized population, they may lack the social capital and resources to effectively manage the increased risks associated with COVID-19 (Bartholomew et al., 2020; Bonn et al., 2020; Tyndall, 2020).

Although the causal mechanisms are unknown, preliminary data report a dramatic increase in overdose fatalities during the pandemic, with more than 93,000 lives lost (Ahmad & Sutton, 2021). However, there are few data to contextualize the specific ways that PWUO have experienced the pandemic and responded to changes.

To address this gap, this article uses postings from PWUO on a web-based forum to examine if, and how, changes to illicit opioid markets related to COVID-19 have affected PWUO. It ends with recommendations for meeting the challenges that COVID-19 poses for this population.

Method

Data for this study comprise postings from Reddit, an online platform used for public discussions on a wide range of topics (Medvedev et al., 2019; Schrader et al., 2020). Reddit is based on user-generated content organized in topic-specific “subreddits,” whereby users (referred to in this article as “Reddit forum users”) can comment on, or “vote” up or down, according to interest. The majority of Reddit postings are in English and its use in the United States is estimated at 11% (Pew Research Center, 2019). Reddit is most popular among U.S. men ages 18–29 (Pew Research Center, 2021).

Like other forms of social media, Reddit is becoming increasingly popular among researchers looking for new and up-to-date sources of data, particularly since the COVID-19 pandemic (Gozzi, 2020; Low 2020). Since it allows conversations to occur in a natural setting, it may provide better data to inform health and drug policy understanding than conversations driven by research questions (Enghoff et al. 2019; Sharma et al., 2017). Indirect methods of data collection like these were recommended by Webb et al. (1999) and others (Kazdin, 1979) for their ability to challenge various kinds of bias associated with more direct approaches. Reddit data have recently been used in a variety of studies on substance use issues, including a content analysis of JUUL discussions (Brett et al., 2019), an examination of PWUO transitions from drug use to addiction (Lu et al., 2019), and an analysis of how social support and networking can aid people's efforts to quit cannabis use (Bunting et al., 2021; Smith et al., 2021; Sowles et al., 2017).

Data collection

Since Reddit contains many subreddits related to substance use, we used membership data posted on each subreddit's home page to select the two most popular opioid-related forums to gather data: “r/Opiates” and “r/OpiatesRecovery.” Although the subreddits did not specify whether discussion should include legal and/or illicit forms of opioid use, posters tended to write primarily about illicit opioid use. This was determined by a preliminary review of recent postings by each author as well as “spot-checking” of posts throughout the subreddit, all of whom found the same focus on illegal drug use. For this study, our definition of “illicit opioid use” included opioids that are, for the most part, always illicit, such as heroin and fentanyl, as well as prescription opioids, like OxyContin, when used nonmedically. We collected the 1,000 most recent posts and subsequent comments from each subreddit at the time of data extraction (a total of 2,000 individual forum posts posted between March 5 and May 13, 2020). We then reviewed extracted posts for their relevance to COVID-19. Relevance was determined using a list of key terms including, “coronavirus,” “COVID-19,” “pandemic,” and “shutdown.” Of the initial 2,000 posts, 300 (15%) were found to be related to COVID-19 and the remaining 1,700 were discarded. Reddit usernames were removed and direct quotes were slightly altered to reduce the risk of searchability and identification (Meacham et al., 2019; Wilkinson & Thelwall, 2011).

Human subjects

Since this social media study was observational and used public non-identifiable data, it was considered not human subjects research and exempt from institutional review board review.

Data analysis

Content was analyzed by a team of nine analysts who had received training in qualitative coding, opioid use, and online Reddit culture. A codebook with 28 codes was created a priori based on the study's themes of interest. Six additional codes were added to the codebook as new themes and ideas arose from user narratives. Data were then examined by the research team using principles of content analysis to identify primary themes and subthemes that arose from the text (Mayring, 2004). Posts were coded along with their subsequent comments, using Atlas.ti (2022) software through a hybrid inductive/deductive approach (Woods et al., 2016). A total of 7% (n = 20) of the posts were initially coded by all analysts to ensure consensus on the codebook and to discover and yield additional concepts and themes that would reveal content for discussion in this exploratory study (Mc-Donald et al., 2019). Afterward, our team met and discussed codes and themes together to note similarities and differences in interpretation of codes and to revise the codebook accordingly. We also discussed new topics and ideas that commonly arose in Reddit posts and added additional codes to the codebook. After multiple discussions and revisions of the codebook, we divided remaining posts to be coded by individual analysts. Exemplary quotes were then selected for inclusion in the article as examples of larger themes that arose in the user content, and wording was altered slightly so that they are not searchable.

To ensure replicability, we had an independent researcher code a random 5% of the data. The researcher was given a 30-minute briefing on the purpose of the research and an overview of the codebook. Interrater reliability (IRR) was then calculated based on Miles and Huberman's (1994) formula for IRR and following further guidance by McAlister et al. (2017). Because the codebook was very large/robust and coders who received more extensive training applied more codes as compared with the independent researcher, IRR was calculated using the number of times Coder 1 (the independent researcher) agreed with Coder 2 (the Reddit study team) divided by the total number of codes used by Coder 1. Following this formula, IRR value was .73.

Results

Changes in drug supply and difficulty obtaining opioids

There were many Reddit posts pertaining to the problems PWUO encountered obtaining opioids after the start of COVID-19. Many described having a regular drug-seller who had previously been able to provide them with opioids on a regular basis but was no longer able to do so. Not surprisingly, this was experienced by PWUO as highly stressful and anxiety producing. For example, the following posts describe people's experience with changes in the illicit drug supply:

Normally I could call him [drug-seller] and get more if needed. But these times have caused too much panic no one wanted to sell any of their scripts. And me being a monster I seen them talking on the news about a quarantine and said, Naw I’ll be able to get more and just blew through my stash. I honestly cried when my dealer said ‘nothing out there’…

My drug of choice has been codeine for many years, so easy to acquire, visit a few pharmacies, perform a [cold-water extract1], nod for a few hours, rinse and repeat… Just before all the lockdowns I had a black-market supplier of pure codeine, thought I was in heaven for a while! And now of course, my connection is gone, and I can't go pharmacy hopping like I once would have and my supply is slowly running out.

Individuals also described increasing attempts by opioid sellers to hoard whatever opioids they are able to obtain. Since the boundaries between opioid sellers and buyers is often fluid and overlapping (Potter, 2009), it is possible that sellers were keeping whatever opioids they had for their own use; however, this is not made clear in the postings. Reddit forum users reported that:

My plug [drug-seller] couldn't get anything or didn't want to give up any of his as everyone was in pain.

Then COVID-19 hit… Everything locked down. Panic everywhere. My dealer didn't want to give up his supply because of uncertainty. My kratom supplier shop shut down.

Reddit posts also suggest that the pandemic has had an impact on the availability of over-the-counter (OTC) opioids as well. Postings reported that OTC opioids like loperamide, an OTC opioid agonist medication, commonly recommended for diarrhea, and used by PWUO both to moderate withdrawal and also to obtain a “high,” were not only more difficult to find, but also more expensive and more heavily secured against theft. Similarly, individuals reported that OTC codeine and kratom were also more difficult to find. The following posts describe such difficulties:

Goddamn ’lopes have become hard/expensive to come by. Even my local dollar store is sold out when they usually have a ton. While this is probably only a symptom of the Covid-19 lockdown, even before they’ve *(in-store)* 1) been impossible to find in bottle quantities 2) gone up in price 3) discontinued 4) placed on anti theft devices 5) limited the # of packages you can buy. I feared after the NYT article in (2017?) things would kind of get fucked for those of us just trying to bridge that gap or ward off [withdrawals], but luckily that didnt seem to happen. Until recently over the last year or 2. Many manufacturers aren't even making 96ct+ even more so it even hard to find online. Have you noticed it getting much harder lately by you too? And whatcha doing about it?

I know someone who takes otc codeine and they said it all got panic bought and the stock is all dried up.

However, descriptions of drug availability were not uniform and likely differed based on geography, setting, and individual network factors. For example, selling cold medications with codeine is legal in some states but illicit in others (National Institute on Drug Abuse, 2017). Similarly, not everyone agreed that COVID-19 had a chilling effect on drug selling. In fact, some posts emphasized that, ironically, drug-sellers were the only occupation to be relatively unscathed by the pandemic's restrictions. For example, Reddit forum users reported that:

The mayor got the whole damn city under lock and key, but that dont stop the dope dealers lol. They out here getting it like the postal service wish it could. I blocked my connects numbers but that [man hit me up] on a separate spoofed number or something this morning, and it took everything in me not to reply back.

I have the exact problem. My main dude is actually punctual and on point during this lockdown bullshit and i had an old plug get back in the game with some really fire stuff.

Reddit posters also reported that drug-sellers were applying social distancing measures to the practice of selling drugs. For example, one post stated that:

My dealer is insisting on social distancing deliveries lol gotta leave the money in the back porch and he’ll leave the drugs in the cooler. If I didn't trust and know the guy I’d be convinced I would be getting ripped off lol but I appreciate the effort.

Yet, posts that described drugs as being more available were in the minority and most of the postings that reference COVID-19's effects on drug availability described a decrease in their ability to procure opioids.

Buying less-trustworthy drugs from lesser-known sources

One result of opioids’ reduced availability was that people buying them often had to settle for something other than their drug of choice. For example, one post by a regular heroin user described getting very sick after having to buy fentanyl instead of heroin because it was the only opioid their drug-seller had available. Although mild nausea is not an uncommon aspect of opioid use and even experienced by some as pleasant, their description clearly locates this as something different and much more severe than what he was used to from previous experiences and thus expecting from this one. They describe:

This batch I got now it's like I get crazy sick. Puke my guts out and keep puking long after it's just bile coming up. Like terribly sick. Anyone else have similar experience with this. It's a new fent [fentanyl] powder. My guy usually just has h [heroin], but his options got slim during quarantine.

Since fentanyl is more potent than heroin and is a well-known driver of the increased rates of overdose (Ciccarone, 2017; Green & Gilbert, 2016; Shover et al., 2020), its use is more risk-involved than heroin (O’Donnell et al., 2017). This is particularly true for individuals who are used to less potent opioids like heroin, who would not only have less physiological tolerance to opioids than someone accustomed to using fentanyl but may also be unfamiliar with how to measure out a proper dose. Moreover, although the poster links his reaction to the presence of fentanyl, it could have also been caused, or exacerbated by, other adulterants increasingly found in illicit opioids (Singh et al., 2020).

Other posts described how the lack of available opioids drove individuals to buy from previously untried, and less trusted, sources. Such arrangements were often organized online with someone whom the buyer had never met, and individuals describe making such purchases despite a high degree of skepticism as to their legitimacy. For example, one poster reported that:

I did order 10 bars from an out of state guy. He of course hasn't hit me back with a tracking number. So I probably just got ripped off. And maybe that's what I get for trusting a dealer out of state haha.

A number of posts also described a recent increase in counterfeit prescription opioids that individuals linked to the decreased availability of opioids. People described buying pills that looked, and sometimes felt, different than what they were used to. Although many expressed skepticism even before buying, the lack of other options meant that many chose to purchase—and use—them anyway.

LATELY, as of May 7th, I’ve been getting Percocet A333 10 mg pills because that is all he has. I wish I could post the picture here so you guys can see, but the pills are SO WEIRD. They are a light beige sort of color and they are grainy. Not grainy in touch but appearance and they have some random blue spots. I stupidly took them because every time I hope it will give me that warmth.. but what I get is comfort, confidence, talkative, my pupils constrict. No unbearable euphoria like I usually get. I always nod out at the end of my high, but these make me nod out hard af.

I’ve been taking M 15s for a bit but dude finally ran out. Got a few blue K9 30's and watched the lady I got them from rail an entire one, but I’m still kind of skeptical. They have a darker blue color and it's consistent color, no white specs or anything. Just wondering if the K9s are also pressed. I know the M 30s are mostly fake.

Some posts directly linked the proliferation of adulterants and counterfeit prescription opioids to COVID-19. They referenced both the increasing scarcity of opioids and the additional financial stress as creating a situation where dealers are more willing to alter the contents of their product for financial gain. Posts, like this one, referenced how the changing market conditions created a greater risk of overdose for people who use illicit opioids:

Unfortunately, this might be your last pickup. But not because you found a way to quit. Every pickup could be your last, especially with fent. We have all told ourselves that lie many times. Not trying to judge or offend. Just viewing your situation from your girlfriend's perspective. It's getting even more difficult for dealers to find stuff with this quarantine. Who knows what they might sell just to make a buck.

With everything in short supply in my area due to being in a high impact Covid zone Ive been seeing a lot more obscure [pills]… These little fucks are built like a brick and impossible to break up. I must’ve ripped over ten bucks in dollar bills tryin to get something close to a powder (I know bioavailability and all that but I just like snorting em and that's how I do).

Stockpiling

In addition to making more risk-involved purchases, posts described a variety of other responses to the increasing scarcity of opioids. For example, some reported trying to stockpile whatever drugs they were able to obtain. However, many also reported that the added stress of COVID-19 made this more difficult. For example, some posts, like the following, described COVID-19 as a catalyst for using up their supply more quickly.

When this whole Covid lockdown thing started I had a massive daily codeine habit which I’ve had for 10 years, weak drug generally compared to Oxy (which I have used and withdrawn from long ago). I had many boxes of 30 mg codeine stashed in my cupboard, and due to boredom and stress my daily use has gone up dramatically- which means I am now about to run out, and as my supply chain has been broken almost completely, I am going to have to get off!

Some individuals also discussed using alternative substances to moderate withdrawal while opioids were difficult to find. There were many posts that referenced using kratom, a legal drug that can be purchased online and is often used to moderate the effects of withdrawal. For example,

With any major lock down a lot of fucking people are going to go into [withdrawals]!! I’ve already thought about it and have a little over 2 kilos of kratom. I’m trying to quit anyways so I’m not worried about not being able to score. Hell I’d be happy if I legit couldn't get it and it wasn't because he was waiting to reup or whatever BS. I suggest people get at least 250 g of good red vein kratom just in case and that would be enough for a week to get past the worst of the WD.

Discussion

These findings examine the ways that COVID-19's destabilizing effects on opioid-selling markets have affected PWUO. They align with related studies that found individuals experienced greater difficulty obtaining opioids on a regular basis and that led to an increase in risk-involved behavior (Ali et al., 2021; Tyndall, 2020). PWUO responded to the changes in a variety of ways, including by purchasing substances from less trustworthy sources, attempting to hoard their drugs, and making efforts to change their substance use patterns. The behaviors known to pose the greatest risk of adverse outcomes were attributable to individuals buying opioids whose authenticity they were less sure of and from sources whom they trusted less.

Research on clinical drug testing shows substantial increases in nonprescribed fentanyl among individuals who tested positive for other drugs since COVID-19 (Niles et al., 2021). Because it is difficult for PWUO (who do not have access to testing services) to know the content or dosage of opioids bought from the illicit market, they rely heavily on established relationships with trusted drug-sellers to mitigate this risk (Carroll et al., 2020). Drug buyers become familiar with the potency of a dealer's particular product and are often informed when the strength of the “brand” changes (Belackova & Vaccaro, 2013; Carroll et al., 2020; Potter, 2009). Thus, the dealer–buyer relationship is an important harm-reduction strategy used by PWUO for regulating the quality and potency of illicit substances. However, since such relationships are part of an informal network used for illicit purposes, they are vulnerable to the effects of disruptive events like COVID-19.

Increased difficulty obtaining opioids also means the PWUO are likely to experience withdrawal more frequently, particularly if they are unable to obtain even legal opioids like kratom. Opioid withdrawal has been shown to increase PWUO's willingness to inject in risky settings, inject with a greater number of partners, and share syringes (Mateu-Gelabert et al., 2010; Phillips, 2016). Thus, the disruption of opioid-selling networks could have a number of negative health outcomes for PWUO. Since our findings show an association between the disruption of opioid-selling networks and negative outcomes, including by purchasing contaminated drugs, the most effective policy responses to this issue are those that focus on providing PWUO with a safe supply of opioids (Bonn et al., 2020; Tyndall, 2020). Legalizing substance use and providing PWUO with access to regulated, quality drugs would be the most effective means of addressing these issues. However, some countries have found ways of providing a safer supply within the larger context of criminalization. For example, in Canada, where safe supply options are more available than in the United States, the government has made temporary changes to the Controlled Drugs & Substances Act that allow for increased flexibility in prescribing opioids to PWUO (Canadian Centre on Substance Use and Addiction, 2020; Health Canada, 2020; Nowell, 2021). Doctors in British Columbia have been advised to provide controlled substances, including diacetylmorphine (heroin), to PWUO who may be at risk of overdose and COVID-19 (Bonn et al., 2020; British Columbia Centre on Substance Use, 2020).

Other ways of protecting PWUO during COVID-19 include improving access to drug testing services, safe-injection (or noninjection use) spaces, and naloxone (Chayama et al., 2020; Niles et al., 2021). Yet, without a large-scale effort to make a safe supply of opioids available to people who use them, drug poisonings will likely continue.

This article should be seen in light of its limitations. First, because this study is based on data from Reddit, an online forum, we were unable to determine the demographic information of individual posters. Demographic data would be helpful toward understanding how these issues affect particular, often multiply marginalized groups. Similarly, in most cases, it was impossible to ascertain the geographic location of individual posters. Since different locations (by country; state, or locality) are subject to different regulations and policy approaches, this information would also be helpful in gaining a more complete picture of how COVID-19 has affected drug-selling networks and people who use them. In general, Reddit is most popular among men ages 18–29 (2021), with most Reddit users residing in the United States, followed by the United Kingdom (8%) and Canada (8%; Statista, 2020). The population of people who post about drug use on Reddit may also be different than other PWUO. Specifically, they may be more stable and/or have greater access to resources than those accessing community-based services and/or individuals experiencing more structural vulnerability such as unstable housing, lack of access to technology, and/or poverty. Data from more marginalized PWUO may show evidence of different responses to COVID-19 and associated changes in drug-selling networks. We recommend that future studies explore these issues with an aim toward understanding the effects of COVID-19, and the policy contexts within which it exists, through methods more focused on specific populations.

However, these results demonstrate some of the ways that COVID-19 has disrupted opioid-selling networks and the consequent increases in risk associated with these changes. If policies are not put in place to deal with the multiple and interrelated problems this population is currently experiencing—especially in the United States, where harm reduction and safe supply options are limited—the combination of COVID-19, existing fragility of opioid-selling markets, and marginalization of people who use drugs will likely lead to a continued increase in harms, including overdose, among this population (Friedman, 2021; Friedman et al., 2021).

Conflict-of-Interest Statement

The authors declare that they have no competing interests.

Footnotes

1

A cold-water extraction is a process in which a substance, in this case opioids, is extracted from a mixture using cold water. It is used in this case to remove non-opioid substances such as ibuprofen, which can cause harm, from opioid-based pills.

David Frank was a postdoctoral fellow in the Behavioral Sciences Training in Drug Abuse Research program supported by Grant No. 5T32 DA007233-35 from the National Institute on Drug Abuse (NIDA) and sponsored by New York University. Samuel R. Freidman was supported by NIDA Grant No. P30 DA011041. Joshua Arshonsky and Marie A. Bragg were supported by a National Institutes of Health (NIH) Early Independence Award (DP5OD021373-05; principal investigator: MarieA. Bragg) from the NIH Office of the Director and 1R01CA248441-01A1.Amanda Bunting was supported by NIH Grants R25DA037190 and K01DA053435 and theAgency for Healthcare Research and Quality Grant T32-HS026120.

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