Thematic analysis of the interviews produced key insights about the mental health and drug use behavior of PWUD during the pandemic. Important themes emerged about (a) increased mental strain, (b) increased drug use, (c) changes in the drug market, and (d) engagement in risky drug seeking and use behavior. Participants also reported difficulty obtaining multiple types of services including (e) treatment, (f) recovery support, and (g) harm reduction. The end of each quote is labeled PWUD or HR to designate which category of participant provided the statement.
Increased Mental Health Strains
Participants reported experiencing heightened levels of stress due to mounting financial uncertainty with the economic conditions brought on by COVID-19. Some PWUD reported losing jobs, losing housing, and increased debt from borrowing money from friends. Others commented on job loss among family members who they rely on for financial support. One participant noted, “my dad is in the entertainment industry…but there’s no events right now… he would supplement his income substitute teaching, but schools are closed” (PWUD). Many made a clear connection between financial challenges and their mental health status. A participant remarked that “financial stress is the most immediate thing…my mental health has declined” (PWUD). A harm reduction worker reported their observation of this connection between financial strains and mental distress among PWUD in their service area stating, “people losing their jobs… it's caused a lot of stress” (HR). Some PWUD also relayed that they experienced anxiety about their lack of insurance should they need to be hospitalized due to contracting COVID. In addition, participants reported that social distancing and isolation have also taken a heavy toll on mental well-being. A participant remarked, “I have anxiety…[I] was diagnosed with depression…it’s made it a lot worse having to stay at home. Not being able to go do things” (PWUD).
Increased Drug Use
Participants reported that the pandemic has triggered increased drug use due financial stress, fear of contracting COVID, and boredom due to joblessness and isolation from friends and family. One PWUD remarked “I definitely have been using drugs more to cope with [stress]. More self-medicating than I have in a long time” (PWUD). Another noted “I’m definitely using more…because I don’t really have anything to do all day. I mean, all day I’m just kind of sitting at home” (PWUD). Some participants reported that people who did not experience joblessness, but transitioned to working at home also increased drug use. One person commented their brother’s drug use saying, “having to be at home now and working off his computer...he has too much time…[he] just sits there in his house and get[s] high” (PWUD). Results from interviews with harm reduction workers corroborated reports from PWUD about increased drug use. Workers highlighted the connection between increased drug use and pandemic-related mental health challenges. One of them stated, “there’s just a lot more use individually, and a lot more use within groups…not having work, being nervous, the anxiety, it’s just leading them to use more than usual” (HR). Increases in drug use related to COVID-19 was described as highly prevalent from both PWUD and harm reduction workers, illustrating an added challenge to the already disadvantaged position of this vulnerable population.
Changes in the Drug Market
Themes emerged pertaining to the drug supply chain including reduced supply, increased demand, decreased quality and purity of the drug supply, and a rise in prices of drugs. COVID-19 prompted significant disruptions to the drug supply chain. One explanation for the decrease in availability is that dealers have less supply. A harm reduction worker noted that “The [drug] supply is dryin' up…there's less product out there in the community” (HR). One reason for the decrease in supply is the reduction in the number of people selling drugs. A worker explained, “a couple of major drug dealers have already closed shop because they … don’t have access to [suppliers]” (HR). Additional participants provided other insights about the reasons for the decrease in supply. A PWUD stated, “well, with the borders [between Mexico and the USA] being shut down, there's not as much drugs coming across” (PWUD). One consequence of the disruption in the supply chain was the increase in drug prices. In some instances, both harm reduction workers and PWUD mentioned increased prices for the same type of drug. A harm reduction worker stated, there’s been crazy spikes in prices, particularly for the methamphetamine, prices have gone up way high. (HR). This observation was corroborated by a PWUD who reported “the prices of methamphetamine’s even gone up” (PWUD). One unexpected outcome of the changes in the drug market was that decreased supply and inflation in prices resulted in decreased consumption for some individuals. One participant reported “tryin' to, like, you know, squeeze a whole lot more out of a dose than I normally would” (PWUD). Another remarked, “it becomes a point where, you know, it's not really available to the point where it's, you know, harder to get than I wanna put effort into” (PWUD).
Increased Risky Behaviors
Due to the low supply and increased price of illicit drugs, harm reduction workers expressed added concerns about the increase in risky substance use behaviors. One behavior is switching the drug of choice. One harm reduction worker remarked, “we’re seeing drugs of choices, and reliable dealers having to be exchanged for questionable substances” (HR) and a PWUD shared “I would say it’s changed… the type of drugs I use…cocaine’s expensive and like, ketamine’s expensive as hell” (PWUD). This highlights how use of specific, more relatively expensive drugs may have decreased, but substance use among individuals increased in possibly riskier ways due to unfamiliarity with different substances. Harm reduction workers also reported that clients in their service areas were engaging in isolated use, putting them at higher risk for fatal overdose. One worker stated, “A lot of people are using alone because of, social distancing…if something happens… there’s not going to be anybody there to help them out with Narcan [overdose reversal drug] or, like, any other form of resuscitation methods” (HR). Another worker remarked on hesitation from drug suppliers to allow PWUD into their homes:
“I’ve seen increased paranoia amongst [dealers], as well, where they’re hesitant to allow people into their apartments. They’re hesitant to allow people into their area because they don’t know if they’ve been infected [with COVID]...[before the pandemic] a lot of the overdose reversals I see taking place, happen in the supplier’s home but one person, in particular, is like, ‘I don’t really know if I want people, like, hanging out here right now.’ And we know that means there’s an increased likelihood of them…using in solitude, by themselves.” (HR, 108).
The impact on safe use practices by COVID-19’s social distancing and quarantine requirements adds to the potential risk of overdose, exacerbating the already present risks of overdose when using substances. In addition to the risks associated with switching drugs, and using drugs alone, workers also expressed concerns about increased risky drug-seeking behaviors. Multiple harm reduction workers shared concerns that people in their service area could be compromising their safety to obtain drugs. One worker shared, “[PWUD] have to take riskier chances to get money...you can't panhandle like a lot of people do…there's just nobody out on the streets [because of COVID] ...so you're seein', uh, riskier behaviors” (HR). Another noted the dangers of PWUD seeking drugs in locations outside of their usual areas remarking, “they’re gonna go outside their community to get what they need, you know, and that puts them at higher risk of not only, you know, COVID-19, but also police persecution, [and] overdose” (HR).
Reduced Access to Treatment and Recovery Support
COVID-19 has an undeniable impact on the mental health and substance use patterns of PWUD and the same is true for harm reduction, treatment, and recovery support services. Participants shared that there was an increased demand for services. A harm reduction worker reported:
Some people who I’ve talked to recently have reported almost wanting to… try to get clean during this time… may as well try to find a detox facility right now or find medication assisted treatment, because either the [drug] prices are so high, or it’s so difficult to obtain. (HR)
Although demand for services increased, participants reported experiences of disruptions and reduced access to providers and resources, including phone lines being rerouted, programs shutting down, and clinics being unresponsive. One participant who was enrolled in a methadone program described their difficulty reaching a caseworker expressing; “now they’ve changed his number where I can’t call him...I would call him like once a week and tell him how I was…how I’m supposed to get in touch with him? I don’t like it at all” (PWUD). This lack or access also affected PWUD who needed recovery support services. Participants indicated that the pandemic had “pretty much stopped AA meetings around, you know, everywhere [making it] kinda difficult for people who are in recovery…[to]maintain sobriety, you know?” (PWUD). As PWUD rely on resources such as support groups and rehab/detox services to sustain recovery, these pandemic-related frustrations caused major disruptions to their recovery path. One participant described the difficulty of getting treatment for a friend: “We tried to get him into a rehab…anybody that we could get to answer the phones, they were like, yeah, we don't know what's going on, just because of this whole COVID thing. We're not getting anybody in anywhere right now.” (PWUD).
Reduced Access to Harm Reduction Services
In addition to lack or disruption of treatment and recovery services, PWUD reported on the diminished availability of harm reduction services. One participant remarked on the lack of access to these services and the resources provided, saying that they “went to a [homeless] camp that's primarily heroin use…[people]said that no [harm reduction worker has] been out there for months. They don't have access to syringes or anything or Narcan” (PWUD). Another participant who disclosed that they were engaged in harm reduction services provided by the same organization for over two year remarked:
[The organization] had a van that would go and meet people five days a week at two locations…but once all this [i.e., the pandemic] started… they immediately cut the five days off, and I think there was a week or two that they didn’t do anything. (PWUD)
Harm reduction workers also shared their experiences and frustrations with their diminished capacity to provide services. They reported rapid and drastic changes in their provision of services and in systemic policy changes due to public health safety measures in response to the pandemic, including relocating service sites, reducing operating hours, suspending services, and stopping face-to-face interactions. One worker remarked, “I cannot go out into the field. I haven’t done outreach…I haven’t seen my patients” (HR). Mitigation of in-person contact was especially damaging to service provision for people living without shelter or homes. One worker shared that before the pandemic workers “used to just go into the [homeless] encampments and talk to everybody that [they] could and now…going into the homeless camp and having a seat and a discussion with folk…that’s no longer happening” (HR). Harm reduction workers also shared that there was negative response in some of their communities regarding their field work. One worker explained:
[We]encountered [opposition] from some of the communities where we normally set up because there's an increased sensitivity to seeing, all of a sudden, large crowds of people with limited access to PPE [personal protective equipment] hovering in areas, in neighborhoods. (HR)
Another worker expressed frustration at systemic changes stemming from competing and often conflicting guidelines from local and state public health agencies saying, "I think that a lot of harm reduction organizations like mine were really impacted by statewide orders that superseded local [orders]” (HR). Harm reduction services being difficult to access despite high demand, increased risky use behaviors. Health and safety for injection drug users were at greater risk. One participant reported, “trying to make [syringes] last longer, and the longer I use ’em, the duller they get, and the more that it ends up really hurting, and it ends up like tearing, you know” (PWUD). Although the pandemic negatively impacted the availability and quality of harm reduction services, one worker viewed the need for rapid organizational change as an opportunity for positive public policy changes stating:
There’s some major regulatory changes…we’re having to coordinate in ways that we never thought of before, and I think what’s gonna come as a result of this is a realization that a lot of the regulations that have been in place actually are unnecessary and actually are contributing to mortality. (HR)
Reduced services that resulted from COVID-19 increased risky behaviors and has drawn attention to the importance of harm reduction work in local communities. Despite the organizational and systemic changes caused by the pandemic, many harm reduction worker remained steadfastly committed to providing services to people in their communities. One worker said:
“A lot of [staff] are still willing to, you know, go in every day and do the work that needs to be done. Because people in harm reduction are very passionate about what they do…the pandemic is a new situation for sure, but, you know, we’ve done it…whether or not it’s safe to do sometimes. Like lines [i.e., COVID safety guidelines] have been crossed for sure. But I think that’s just because, the drive, and the passion.” (HR).