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. 2020 Jul 3;83:102832. doi: 10.1016/j.drugpo.2020.102832

COVID-19 - Enacting a ‘new normal’ for people who use drugs

Judy Chang 1,⁎, Jake Agliata 1, Mauro Guarinieri 1
PMCID: PMC7332951  PMID: 32654930

Abstract

The COVID-19 crisis has magnified existing social, economic and political inequities. People who use drugs are particularly vulnerable due to criminalisation and stigma and often experience underlying health conditions, higher rates of poverty, unemployment and homelessness, as well as a lack of access to vital resources – putting them at greater risk of infection. On the other hand, COVID-19 presents an opportunity to confront the mistakes of the past and re-negotiate a new social contract. The International Network of People who use Drugs (INPUD) believe that this crisis must be an occasion to rethink the function of punishment, to reform the system and to work towards ending the war on drugs. This commentary presents a set of recommendations to UN agencies, governments, donor agencies, academics, researchers and civil society, challenging these actors to work alongside people who use drugs to enact a new reality based on solidarity and cooperation, protection of health, restoration of rights and dignity and most importantly to mobilise to win the peace.

Keywords: COVID-19, People who use drugs, Community engagement, Criminalisation

Introduction

On the 3rd of April, 2020 the Financial Times editorial opined that the COVID-19 virus has laid bare the frailty of our contemporary social contract, compelling humanity to consider the radical reforms required to forge a society that will work for the common benefit (2020).

Much like other cataclysmic moments in history such as the Spanish Flu, the Great Depression and two World Wars, the COVID-19 pandemic forces us to confront the shortcomings of the world we have created. The COVID-19 crisis has exposed the unpreparedness and brittleness of our health systems and economies; a result of the failures of our political, legal and social structures and institutions. Competing ideas, visions and influences are jockeying for political primacy as we collectively grapple with the question of what kind of society will, and what kind of society we want to emerge from COVID-19 induced changes and disruptions. On the one hand, ideas and proposals previously considered fringe or eccentric such as universal health care, universal income and wealth taxes are being considered as viable policy changes to bridge ever more visible disparities and inequalities (Hirsch, 2020; King, 2020). On the other hand, draconian COVID-19 emergency measures may be indefinitely extended to further entrench these same inequalities, silence opposition and suppress dissent. The decisions and actions we take now will have profound ripple effects on our future economy, politics and culture, as well as shape social relationships and the ways in which we approach public and civic space. Simply put, the opportunity to construct the post-COVID world is here and now.

The COVID-19 crisis has highlighted that political realities are not fixed, but emergent and therefore open to change. As political commentators and opinion leaders urge us to re-think, renegotiate and renew our social contract in the time of COVID-19 we must turn our efforts to righting political wrongs, particularly those perpetrated against the most marginalised. From its beginnings the War on Drugs has had devastating health, economic and social consequences on the lives of people who use drugs (Jensen, Gerber & Mosher, 2004). The global pandemic is escalating the human cost of this policy failure. A revitalised social contract has to reconsider the function of punishment and invest in creating a new normal for and with people who use drugs.

People who use drugs, of which there are an estimated 35 million globally, are particularly vulnerable during times of crisis (UNODC, 2019). Criminalisation has pushed people who use drugs to the margins of society, with a disproportionate number experiencing poverty, homelessness, incarceration, work in the informal economy, underlying health conditions and lack of access to vital resources; making the community highly susceptible to the secondary impacts and fallout of COVID-19 (Dunlop et al., 2020; Farhoudian et al., 2020; UNODC, 2020). Many, especially those whose circumstances deter compliance with lockdown measures, are easy scapegoats for police and authorities. Whilst COVID-19 cases amongst people who use drugs remains still unknown, there is no doubt the community of people who use drugs have been inordinately impacted by ongoing waves of epidemics, including HIV, Hepatitis C and the opioid overdose epidemic. The figures are joltingly stark; in 2017 an estimated 585,000 died of a drug overdose (UNODC, 2019). People who inject drugs are 22 times more likely to be living with HIV than the general population, with 17.8% of the estimated 15.6 million people who inject drugs living with HIV and 52.3% living with Hepatitis C (UNAIDS, 2019; Degenhardt et al., 2017). Despite the loss of life and devastation wrought by these extant epidemics, people who use drugs have emerged as resilient, applying community survival strategies and becoming highly attuned to the politics of life and death.

Hard-earned lessons on managing public health crises and their inherent tensions with individual human rights imperatives have been collected along the way. These can be applied in the here and now. Throughout history fear of the unknown and fears of contagion have preceded the imposition of authoritarian measures and restrictions, which have worsened the situation. Outbreaks of syphilis and the HIV epidemic either led to, or were used as a pretext to persecute sex workers, gay men, transgender people and people who use drugs in the name of infection control (Chan & Reidpath, 2003). Today, in a seeming repeat of history, we are witnessing the deployment of militarised language and jargon by governments, emphasising that we are fighting a ‘war’ in lieu of accentuating the importance of solidarity and social cohesion. The form and function of this rhetoric justifies the suspension of rights and freedoms and facilitates the introduction of exceptional measures such as curfews, forced quarantine, isolation and slum clearances. Echoing the ‘war’ on drugs, this language normalises the idea that war is fought between a ‘good’ actor and a ‘bad’ actor, perpetuating stigmatisation of key populations.

The International Network of People who Use Drugs (INPUD) is the global peak-body representing people who use drugs. We have received multiple reports from member networks of people who use drugs being violently forced by authorities into rehabilitation centres and denied access to medication. A legitimate concern of ours is that authoritarian power is being left unchecked beyond the limits of containing COVID-19 and deployed against criminalised populations. Moreover, the imposition of social-distancing language and measures introduces the idea that social interactions are dangerous by nature, when on the contrary it is the knowledge and experience of communities that are needed more than ever. Materially, social distancing language and measures threaten to worsen the ongoing overdose crisis as peers are faced with contradictory public health messaging (never use alone/self-isolate) and as community solidarity initiatives are being restricted. In recognition of such contradictions, the World Health Organization (WHO) has recommended replacing the language of social-distancing with physical distancing to emphasise the importance of social connection, solidarity and information-sharing in battling this pandemic (Aziz, 2020).

The COVID-19 pandemic throws that which is already broken into sharp relief; over-extended carceral systems, neglected health systems and disregard of the social and structural determinants to health. Early on multiple actors, including UN agencies, doctors and advocates called for prisoner release schemes to prevent COVID-19 (Holpuch, 2020). Only a however have drawn attention to global policies that drive bodies into the criminal justice system, such as the War on Drugs itself (Cardoso, Dreifuss & Clark, 2020). It was the global HIV movement that showed us the social shape of epidemics. Criminalisation of key populations, including people who use drugs, has driven epidemics by forcing people underground and making it harder to access health and social services (DeBeck et al., 2017). Albeit, HIV also pointed the world to solutions, including the pathways towards more equitable health and community systems and of addressing stigma and discrimination. Since the COVID-19 outbreak, as was the case in the early days of the HIV epidemic, communities of key populations have been on the frontlines, drawing on their distinctive knowledge of community needs, to educate, empower and advocate (Frontline AIDS, 2020). The political participation of people who use drugs, combined with decriminalisation, decarceration and ensuring the accessibility of funding for community-led networks will be crucial to addressing this global pandemic, along with  the political leadership of UN agencies, academics and researchers, government officials and advocates for social justice.

In consultation with our networks and communities, INPUD has identified the following key trends and concerns regarding the impact of COVID-19 on people who use drugs (INPUD, 2020b):

Harm reduction services and programmes

Harm reduction services such as needle and syringe programmes (NSP) or opiate treatment programs (OTP) have always struggled for adequate funding and political support, leaving them under-equipped, understaffed and struggling to cope with COVID-19. From March 2020 onwards, people who use drugs have faced further limitations in accessing harm reduction services, whether that be due to service closures, failure to sufficiently adapt to changing contexts or having already scarce resources diverted to the COVID-19 response (INPUD, 2020b). To put this in context, a 2017 Lancet journal article estimated that less than 1% of people who inject drugs live in countries with high coverage of harm reduction programmes (Larney et al., 2017). Reports of service closures and disruptions have been documented and reported by communities in the United States Western and Eastern, Europe, sub-Saharan Africa and Latin America and the Caribbean (Dastmalchi, 2020; Dunlop et al., 2020; INPUD, 2020b; Sarosi, 2020). A U.S rapid mixed methods assessment found that 43% of NSP's reported a decrease in availability of services, whilst in the state of Ohio, more than 50% of NSP's have been shut down, with personnel and resources diverted to combat the current pandemic (Dastmalchi, 2020; Glick et al., 2020). Such actions increase risk of HIV acquisition as well as COVID-19 due to overcrowding of existing services. Lockdown measures and movement restrictions have limited the operation of services and disrupted global supply chains of essential supplies, as well as made it harder than ever for people who use drugs to travel to their harm reduction service (ENPUD, 2020; INPUD, 2020b). In some cases, personal protective equipment (PPE) remains unavailable for NGO-run harm reduction staff and clients (Glick et al., 2020). Harm reduction services are often the only contact point for people who use drugs to access health services, health education, social protection and other essential life-saving services.

On the other hand, the corollary effects of COVID-19 is the scrutiny brought to the apparatus of harm reduction and drug treatment. Drug user advocates have long pointed towards the often punitive, overly rigid and inflexible rules and regulations of methadone and buprenorphine programmes, protestations which have been met with dismissal or disregard. The sudden introduction of COVID-19 protective measures has demanded a re-think, with many programmes rapidly introducing take-home doses, removing arbitrary rules and regulations such as compulsory urine testing or daily witnessed ingestion and coming up with flexible and innovative ways to deliver OTP's, as well as drug-using equipment to curtail person-to-person interactions. Encouragingly some clients and programmes have reported an increase in access to needles and syringes, OTP's and naloxone, with models such as telemedicine, secondary distribution, flexible dosing and home delivery being introduced as a matter of compliance with lockdowns and physical distancing measures (Bach, Robinson, Sutherland & Brar, 2020; EMCDDA, 2020; Glick et al., 2020; INPUD, 2020b).

Community networks across South Asia, Eastern Europe and Central Asia and Western Europe were central to making these changes a reality. Academics and researchers alike have long criticised the ways in which rules and regulations of drug treatment are experienced as punitive and more invested in exerting social control rather than providing humane and respectful care (Fraser & valentin, 2008). That it took a pandemic to compel a shift in harm reduction practice, despite years of community demand is testimony to the ongoing silencing and suppression of community perspectives and demands. The work to sustain these changes post-crisis remains ongoing and will attest to what lessons have been learnt.

Safe supply

Safe supply refers to a legal and regulated supply of drugs, such as heroin, stimulants and hallucinogens that have traditionally been accessible only through the illicit market. Globally, border closures, travel bans and movement restrictions are impacting the predictable supply of unregulated substances, meaning more people than ever will be in need of safe supply (CCSA, 2020). Sixty two percent of respondents on a survey on COVID-19 and drug markets reported changes to the availability, price and variety of products, prompting concern around the circulation of increasing harms (Crew, 2020). Worldwide people who use drugs are facing involuntary withdrawals related to changes in the drug market, inability to purchase drugs due to loss of income or restricted movement (Guirguis, 2020; INPUD, 2020b). Across North America, reports of spikes in overdose calls and deaths have been connected to COVID-19, either due to changes in drug supply, more people using alone or attempted suicide, with emergency responders in some jurisdictions receiving directives limiting their ability to respond to most overdoses (Kaur, 2020). The targeting of people who sell drugs, of whom many are trusted sources for peers, reduces the availability of safer drugs on the illicit market. Prior to COVID-19 safe supply had been posed as a solution by peers in Canada as a means to mitigate the country's ongoing overdose crisis, end stigmatisation of drug use, restore dignity and to effectively reduce harms and improve quality of life (CAPUD, 2019). More than ever the safe supply of unadulterated and regulated substances will be crucial to saving lives. In March, 2020, in response to COVID-19, the British Columbia Centre on Substance Use (BCCSU) along with the British Ministry of Health published guidelines on the safe supply of pharmaceutical grade opioids and stimulants which emphasised flexible dispensing and client discretion to support them in the goal of physical distancing (2020; Bach et al., 2020). This presents another example of where COVID-19 created space for ‘experts’ to adopt community-led solutions and enact changes that peers had long fought for.

Criminalisation, prisons and mass incarceration

The COVID-19 crisis has thrown the over-extended carceral system into sharp relief by spotlighting the public health dangers nested within prison and detention facilities. General prison conditions, such as overcrowding, poor ventilation and shared living quarters combined with the lack of access to prevention commodities, testing, diagnosis and treatment, has meant that prisons have traditionally been hotbeds for infectious diseases such as HIV, HCV and Tuberculosis (Nijwahan, 2016; Harm Reduction International, 2018). Given these conditions, the risk for a COVID-19 outbreak is high and makes COVID-19 prevention measures virtually impossible to implement (OHCHR, 2020).

Today, outdated criminal laws are threatening even more lives. According to UN data, at least 470,000 persons are incarcerated worldwide for drug use and possession only, while an additional 1.7 million people are incarcerated for other drug offences, with another 600,000 detained against their will in drug treatment facilities in East and South-east Asia and Latin America (IDPC, 2019; UN System Coordination Task Team, 2019). In response to  the COVID-19 pandemic more than 50 countries, including France, Turkey, Indonesia, Brazil, Nigeria, Iran, Myanmar and the Philippines, have taken steps to reduce their prison populations through the release of detainees in line with the UN High Commissioner for Human Rights COVID-19 statement on prisoners (Bach et al., 2020; Lines, Burke-Shynes & Garelli, 2020). As of April 19th, 2020 the number of people released number more than 300,000; however though it remains unclear precisely how many were charged with non-violent drug offences, some prison release schemes specifically targeted this group (Lines et al., 2020). Unexpected and unparalleled, former world leaders attest that this move by governments indicates that ‘authorities in very different parts of the world are implicitly admitting that drug sentences were unnecessarily harsh and disproportionate’ (Cardoso et al., 2020).

Made self-evident by COVID-19, there has always been an undeniable moral case to accelerate pardons and amnesties of people incarcerated for drug-related offences, including for low-level dealing. Many people who sell drugs do so as a matter of survival. Surprisingly, early releases and amnesties have not faced major opposition nor ideological resistance, providing a rare window of opportunity to radically reform the prohibitionist agenda which drives mass incarceration. Originally borne of racism and fear-mongering of Chinese immigrants, through the passing of the Harrison Act (1914) in the United States that targeted Chinese migrant labourers, the War on Drugs has never truly been about ameliorating potential harms associated with drug use and more about justifying the denial of rights to certain populations, particularly people of colour, by inculcating moral panics and criminalising behaviour (McCaffrey, 2019; Provine, 2011). The COVID-19 pandemic has generated a wave of stigma, racism and xenophobia, further entrenching racial inequalities (UN News, 2020). Global leaders and influential commentators should commandeer the opportunity to end the global war on drugs, which is one of the most abysmal, yet entrenched, policy failures of our time.

Contesting the authoritarian ‘new normal’

Declaring states of emergency has meant the suspension of rights and freedoms normally guaranteed under the Constitution or basic law of the country. Many governments, in the name of epidemic control, are restricting civil liberties in unprecedented ways, through mass surveillance including tracking mobile phone data, restricting movement and banning public assembly. State authorities are permitted to stop anyone on the street, increasing the chance of interactions with hostile police for people who use drugs, people who sell drugs and other criminalised populations (Human Rights Watch, 2020; UNAIDS, 2020). Because of this, as INPUD members have reported, people who use drugs are stockpiling drug supplies to stay safe, putting them at greater risk of criminal sanctions and higher penalties. For people who use drugs living on the streets, it has not been uncommon to be rounded up, beaten and harassed by law-enforcement officials or sent involuntarily to ‘quarantine camps’ (INPUD, 2020b).

Moreover, the potential misuse of personal data, particularly when it comes to criminalised populations, is of acute concern. Several governments have deployed sophisticated surveillance technologies to track and monitor people. Mobile phone applications are being used to produce real-time case management of positive cases, as well as enabling digital contact tracing, warning people of their proximity to infected people in China, South Korea, Singapore, Italy and other European countries. As Davis points out, publishing location data on COVID-19 outbreaks may intensify the climate of stigma and blame towards specific minority groups (Davis, 2020). Here, past lessons from the public health dimensions of HIV are important. Criminalised and stigmatised populations, such as people who use drugs, LGBT people and sex workers have shied away from inclusion in HIV surveillance studies out of a fear of arrest. It is important that this virus not mark a turning point in the history of surveillance, whereby the race to embrace mass surveillance tools without right to privacy safeguards may undermine the goal of epidemic control (ibid. 2020).

In summary, the seriousness of COVID-19 should not be exploited to indefinitely suspend basic rights and freedoms, but be a wake up call to change and repair a broken system overly focused on the punishment and social control of people who use drugs.

Communities: solidarity, dignity and cooperation

The COVID-19 pandemic has brought the critical role of communities into sharp relief because communities are able to detect early, respond quickly and reach those who are otherwise unreachable by the healthcare systems, easing the burden on health administrators and frontline workers. Additionally, communities play important watchdog functions when it comes to government transparency and accountability. Since early March, 2020, INPUD and its sister organisations around the world rapidly mobilised to develop online peer resources and educational materials, write statements and guidelines and provide direct outreach services (INPUD, 2020a). The COVID-19 crisis has unseated faith in the fitness of political systems and political leaders. This is the time for new solutions grounded in the realities of people facing the harshest repercussions. From the annals of lived experience, we have always known the solutions that are needed for people who use drugs. The essential role of communities in the HIV movement reshaped the global health agenda in critical ways, including drawing the world's attention to the social-structural determinants of health, biopower and biopolitics and embedding the principle of meaningful community involvement within the rigid and depersonalised corridors of public health (Foucault, 1976; Rodriguez-García et al., 2013). Today, these past lessons are being brought into sharper focus.

Call to action

The political strategy for confronting COVID-19 is still taking shape. More than ever, community-led solutions and injunctions on navigating us out of this current crisis should be heeded by UN agencies, governments, donor agencies, academics and researchers and civil society actors. This is the time to enact and forge new realities and architectures of drug policy for and with people who use drugs, and by extension wider society.

The International Network of People who use Drugs strongly urge for the following recommendations to be taken up:-

  • 1. Ensure unimpeded access to harm reduction programmes

  • a)

    Declare harm reduction programmes, including supervised drug consumptions rooms as essential life-saving services that must stay open

  • b)

    Design and implement programmes in ways that both accord with COVID-19 protection measures and with the needs of people who use drugs

  • c)

    Amend legal and regulatory policies and practices that ban or limit take-home doses and restrict the provision of naloxone and secondary distribution channels

  • d)

    Coordinate efforts within the health system to facilitate the effective distribution of resources, including PPE and other commodities

  • e)

    Ensure that community-endorsed changes made to harm reduction programmes, such as flexible dosing and dispensing are sustained beyond COVID-19

  • 2) Ensure safe supply of drugs through a two-pronged effort of rational management of the drug market and increasing access to legal and regulated drug supplies

  • a)

    Monitor trends of drug markets, including through supporting drug-checking services and deprioritising supply-side control in order to retain stability in illicit drug markets and prevent market saturation of synthetic drugs

  • b)

    Introduce, accelerate and sustain safe supply programs; ensure access to appropriate pharmacotherapy through accelerated and flexible entry protocols in line with the British Columbia Centre on Substance Use's risk-mitigation guidelines

  • c)

    Set up early warning systems to detect potential disruptions in the production and transport of methadone and buprenorphine and step in when early signs of issues with supply chain management are detected

  • 3) Social protection schemes must be available for people who use drugs, particularly for those who face housing and food insecurity

  • a)

    Ensure access by establishing referral linkages with community-based harm reduction services to support people who use drugs to navigate entry procedures

  • b)

    Waive the requirement for ID and registration documents for those in critical need

  • 4) Acknowledge that criminal justice reform is long overdue and decriminalise drug use and possession

  • a)

    Decriminalise drug use and possession in line with the UN system in the UN Common Position on Drugs. Decriminalisation should extend to the low-level supply of drugs

  • b)

    Reduce the prison population through early release, pardons and amnesties for people detained for drug-related non-violent offences, including people who sell drugs

  • c)

    Immediately release those held in compulsory drug detention and involuntarily detained in private rehab centres that apply coercive measures

  • 5. Protect civil and political liberties as a fundamental prerequisite.

  • a)

    States must act in accordance with the Siracusa Principles when applying COVID-19 related measures and restrictions that may impinge on human rights

  • b)

    Ensure that emergency declarations and broader extraordinary powers granted under COVID-19 responses are not used to target specific populations or deployed to silence and repress human rights defenders

  • c)

    Establish rights-based legal safeguards to govern the appropriate use and handling of personal data to protect privacy and confidentiality

  • d)

    Ensure client confidentiality is protected and data not used to target and punish people with COVID-19 or people who use drugs

  • e)

    Ensure people who use and sell drugs are not being targeted by law-enforcement or other actors in discriminatory ways

  • 6. Safeguard community and civil society autonomy

  • a)

    Ensure governments do not impose disproportionate restrictions or obstructions on the work of community and civil society organisations

  • b)

    Establish mechanisms for monitoring human rights compliance, with a particular focus on populations whose rights are commonly violated

  • c)

    Flexible funding should be made available to community and civil society organisations during this time of high need and uncertainty

Conclusion

Global health has never been neutral, but always embedded in and constructed through political, social and cultural contexts. In recent years, multilateralism has faced ever-growing threats to its legitimacy, but as COVID-19 is making clear, an effective response for a global pandemic cannot be mounted without an accompanying global response. Whether it is for the development of a vaccine or for handling the economic fallout or coordinating supply chains and standardising protocols, global leadership will be key in coordinating this response. However, having borne witness to the devastating impact of the global war on drugs, people who use drugs are all too aware that the promise and powers of multilateralism can be harnessed for either good or bad. Criminalisation of drug use is currently being propped up by the three drug control treaties and must be superseded by a treaty for Drug War Peace. The language of ‘war’ has been weaponised against people who use drugs for far too long. It is high time to shift our language and thereby our strategies from a stance of conflict to cooperation; both between and within states. In the time of COVID-19, we call on UN agencies, academics and opinion leaders to call for an end to the criminalisation of drug use. On the 13th of May, a joint statement by UNODC, OHCHR, WHO and UNAIDS on COVID-19 and prisons urged political leaders to reduce prison overcrowding by limiting the deprivation of liberty and releasing those held on minor, non-violent offences (2020), but failed to harness the political opportunity to call for an end to the War on Drugs – the policy culprit driving mass incarceration. This failure of political courage is that which is driving the problem itself. What type of world will emerge post COVID-19 is still up for contestation. In order to sustain hope for a more equal and just world, we need to be working with common purpose to enact a new reality based on solidarity and cooperation, protection of the health and restoration of the rights and dignity of people who use drugs and mobilising to win the peace.

Declaration of Competing Interests

The authors have no conflict of interest. No financial support was provided for the completion of this article.

Acknowledgements

This commentary draws from the global sign-on letter 'In the time of COVID-19: Civil Society Statement on COVID-19 and People who Use Drugs' by the International Network of People who Use Drugs (INPUD), the International Drug Policy Consortium (IDPC) and Harm Reduction International (HRI) published on April 7th, 2020. Over 300 organisations and individuals endorsed the recommendations.

The authors would like to thank Dr. Andrew Guise, King's College, London for providing insightful feedback on the commentary. We would also like to thank the communities of people who use drugs around the world who are always on the frontlines in times of crisis.

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