Public health messaging and harm reduction in the time of COVID-19

Coronavirus disease 2019 (COVID-19) was declared a pandemic on March 11, and the disease is now expected to spread to most countries, if not all.¹ The public health messaging mainly concerns personal hygiene, physical distancing, respiratory etiquette, stocking up on food supplies and essential medicines, contact tracing, and staying indoors as much as possible. We are concerned that the current public health messaging might be leaving out an important at-risk population: people who use drugs, including beverage and non-beverage alcohol, and in particular, individuals who are marginalised and street entrenched. Marginalised people who use drugs might be at an increased risk of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection, and of poor outcomes of COVID-19, because of limited personal resources, unstable and densely populated housing conditions, substance use sharing practices, and compromised immunity (eg, in individuals living with HIV, chronic obstructive pulmonary disease, and other comorbidities). Other concerns pertain to limited access to essential medicines (including opioid agonist treatments) and harm reduction supplies.

Investments in harm reduction supplies and services need to be expanded now. These investments should focus on increasing supplies for safer smoking, snorting, and injecting drug use, access to alternatives to non-beverage alcohol, and providing sanitising supplies and educational materials in harm reduction packages. Harm reduction services should prepare for logistical challenges by developing emergency plans for potential volunteer and employee absences, illness, and burnout as well as communication plans in case of service disruption in essential services (eg, access to prescribed medications, safe consumption rooms, and overdose prevention sites). Treatment continuity plans (eg, permitting online visits, phone-based refills, extended prescriptions, permitting take-home doses, permitting prescriptions to be transferred between pharmacies, and providing ongoing access through outreach and delivery options) are needed for individuals living with HIV, hepatitis C virus, and substance use disorders. Because emergency services are likely to be overburdened, responses to overdoses or other medical emergencies related to substance use (eg, severe alcohol withdrawal) might be delayed; efforts should be made to ensure access to appropriate clinical sites and specialist care, as well as a high penetration and uninterrupted supply of naloxone kits. In settings such as those in North America, where there is an influx of fentanyl and its analogues,² scaling up services to provide a safer supply of drugs, tablet-based and injectable agonist treatments, and slow-release oral morphine could help mitigate transmission of SARS-CoV-2 by reducing the need to spend time outdoors procuring drugs: these interventions could rapidly be incorporated in existing harm reduction services.3, 4, 5

Developing public health messaging tailored towards marginalised people who use drugs is of utmost importance. These messages should highlight the need to minimise sharing substance use supplies because respiratory infectious diseases can be easily transmitted via e-cigarettes, pipes, and nasal tubes. In situations in which sharing supplies is inevitable, harm reduction messages should emphasise washing or sanitising hands before substance use, wiping the supplies and surfaces used for drug preparation with alcohol or disinfectants, and stocking up on supplies to avoid unnecessary trips to harm reduction facilities. Public health messages around self-isolation and physical distancing should be modified for people who use drugs who live in shelters or who are involved in sex work.

As a society, we can protect vulnerable populations by practising the fundamentals of public health and prevention science. We have a moral, societal, and professional responsibility to ensure that people living on the margins are not left out of these efforts.