Impact of COVID-19 on New Mexico Harm Reduction Services: Challenges and Recommendations

Evidence is emerging indicating persons with substance use disorders (SUD) are at particular risk of adverse health outcomes during the Sars-CoV2 pandemic crisis, especially compounded if those persons are underrepresented minorities. New Mexico has unique demographic characteristics being predominantly rural and minority populated. We attempted to survey harm reduction (HR) sites across the state to understand and document the effects the current health crisis has had on their operations. Sites reported a signicant decrease (p=0.05) in clients served between the time periods of November 2019-January 2020 and March-May 2020, supply shortages, and anecdotal reports of increasing street drug prices. Future research should focus on rates of overdose during public health crises, its effects on medication assisted treatment (MAT) clinics, and in continued efforts to curtail rates of SUD overall.

. ;Saloner, et al., 2018.;Aspinall, et al., 2013.). According to the NMDOH, New Mexico currently accounts for 7-8% of all syringe services in the United States, with a 50% increase in syringe service program enrollments since 2012. Current HR services offered in New Mexico include, but are not limited to, syringe services, overdose prevention training, naloxone distribution, social services referrals, primary medical care referrals etc. In New Mexico, there are 12 state-contracted HR sites and 38 Public Health O ces that provide HR services; these sites are especially crucial to ghting the opioid epidemic in rural areas (NMDOH).
SARS-CoV-2 arrived in New Mexico on March 11th, 2020 with four travelers returning from international vacations. Given the poor baseline health of the state's population, unequal distribution of hospital beds, and limited infrastructure for intensive care surge capacity, the state government recognized the potential for catastrophe and moved quickly to prevent spread of the virus. On March 23rd, New Mexico Governor Michelle Lujan Grisham announced a statewide 'stay-at-home' order. The order required that all schools, universities, and non-essential businesses in the state close, and that people leave their homes only for outings "necessary for their health, safety, or welfare" (CABQ, 2020.). Harm reduction sites were allowed to stay open as they were deemed essential in alignment with the American Medical Association's (AMA) position statement recommending that syringe exchange and naloxone distribution be maintained and prioritized during such closures (AMA, 2020). Medical practices in the state were referred to the Center for Disease Control (CDC) guidance for COVID-safe practice changes. The CDC guidelines recommended maximization of telehealth services; limiting number of visitors and daily appointments; physical distancing of six feet or more; increased screening and sanitizing practices; and visual aids indicating the new guidelines and encouraging hand hygiene (CDC, 2020).
Despite the lock-down, by mid-April, McKinley and San Juan counties became a national virus hotspot with per-capita infection and death rates comparable to and eventually surpassing New York City (Silverman, 2020). The Native American communities in these counties, particularly individuals from the Navajo Nation, were especially hard-hit with 8,837 con rmed cases and 434 deaths in July (Navajo Nation DOH, 2020). The SARS-CoV-2 pandemic has been especially harmful for individuals from minority groups, with minority death rates over two-fold higher than for white individuals reported in many states (Kaur, 2020;Dorn, et al. 2020). Similarly, the virus appears to be especially harmful for those with SUD.
Preliminary research ndings have demonstrated high infection rates and mortality among people with SUD (Wei, et al. 2020). Given that New Mexico has large numbers of people using HR services particularly in rural and minority populated areas, we wished to investigate the impact of the pandemic on HR. Our study uses cross-sectional survey methods to investigate the impact of the SARS-CoV-2 pandemic on HR services in New Mexico.

Materials
Survey Design: The survey questionnaire was developed by the researchers of this project. The survey was designed to measure the degree to which HR sites have been impacted by the SARS-CoV-2 pandemic. The survey questionnaire included a total of thirty questions, with additional branching/follow-up questions for speci c answers. Rural versus metropolitan metro sites were determined by self-reporting rural or urban areas served. See Appendix A for the complete list of questionnaire items.

Participants
Recruitment/ Study Population and Sampling: A list of all operating HR sites in the state of New Mexico were provided by the NMDOH. Sites designated as exclusively syringe drop off boxes were excluded. A total of fty HR sites were identi ed: twelve sites were independently operated and contracted with the state, and 38 sites were associated with NMDOH public health o ces. Each of the fty HR sites were emailed a request for participation, provided informed consent documentation and a URL to the REDCap survey questionnaire. Responses were submitted and collected through the REDCap database system.

Data collection:
One survey was administered per HR site, to be lled out by one designated employee of the site's choice. Participants were told the survey was designed to better understand how stay-at-home orders and the SARS-CoV-2 pandemic are impacting the provision of HR services in the state of New Mexico. A consent form was sent with the survey link, outlining the bene ts and risks of participating in the study. After reading the consent, participants had the choice to participate by clicking the survey link or declining participation. Participants generally completed the questionnaire within thirty minutes, were thanked for their participation, and were dismissed. No nancial or other tokens of gratitude were provided for survey completion.

Data analysis and availability:
Data was collected into RedCap and simple summary statistics were completed using Microsoft Excel version 16.38. Data distribution analysis revealed skewing for most site characteristic data. Chi-square tests were used for multiple comparisons of the categorical data. The datasets generated during and/or analysed during the current study are available from the corresponding author on reasonable request.

Study Limitations:
As with all survey data collection, self-report and recall bias were limitations to these methods.
Additionally, asking participants to recall information from prior months may lead to inaccuracy of certain data points.

Results
A total of 12 independently operated HR sites and the NMDOH were invited to participate in this study. The NMDOH operates 38 sites throughout the state and elected to have a single respondent complete the survey providing an average for the 38 sites. Of the 13 total surveys sent there was a 100% response rate, representing 50 HR sites across the state. Characteristics of the sites in the three months prior to and during the SARS-CoV-2 pandemic response in New Mexico are shown in Table 1. In the three months prior to the Governor's stay-at-home order issued on 12 March 2020, the majority of sites reported an average of over 51 clients per week (44/50, 88%), had 4-5 staff/volunteers on site (43/50, 86%), were open 5 days per week (48/50 96%), and served a rural area (42/50, 84%). Prior to the pandemic, seven sites offered street or van outreach (7/50, 14%).
After the stay-at home order was issued, most HR sites continued to provide services at levels nearly comparable to pre-pandemic operations (Table 1), with the exception of two independently-operated sites that discontinued HR services entirely (2/50, 4%). Both of these closed sites provided street outreach. One  Table 2 shows the service changes reported by HR sites in response to the SARS-CoV-2 pandemic. Some respondents from independent HR sites noted reduction in HR service hours (4/10, 40%). Most independent sites, those not operated by the DOH, reported a decrease in their monthly budget after the start of the pandemic (5/10, 50%). While operations continued, most sites reported scarcity in supplies with syringes, tourniquets, and biohazard containers all in short supply (8/10, 80%). In comment boxes provided in the survey, some sites noted that they had to limit the number of syringes exchanged per client and others noted that HR services had been moved outdoors to limit the number of people entering their facility. For sites that remained open, the distribution of naloxone kits and fentanyl test strips remained nearly constant despite the pandemic. Most independent HR sites reported that they had to reduce services during the pandemic (5/10, 50%). Reduced services included HIV and HCV testing, group sessions, clinical procedures, and street outreach. While many sites reduced services, some were also able to add new services during the pandemic (6/10, 60%). Some of the new services noted were the provision of masks, gloves, hand hygiene supplies, expansion of social services (e.g. food), and telemedicine expansion for buprenorphine patients.
Subjective questions were included in the survey to attempt to understand how the stay-at-home order and pandemic had altered the HR community experiences ( Table 3). The data from the NMDOH sites was considered as a single respondent for the subjective analysis. Only 2 of the 13 respondents reported awareness of any clients who tested positive for SARS-CoV-2. A few responded that clients had reported street drug scarcity (2/13, 15%) and price increases (3/13, 26%) due to the pandemic, as well as increased incidence of opioid and alcohol withdrawal (each with 1 of 13 respondents, 8%). Only one respondent reported an increase in drug overdose deaths (8%).

Discussion
Due to the implementation of SARS-CoV-2 policies and precautions, especially social distancing, patients with SUD are at an increased vulnerability to adverse outcomes related to substance use (Douglas, et al. 2020). Increased isolation worsens comorbid mental health disorders and symptoms, increasing the risk of use and overdose (Schimmel, et al. 2020). Further, social isolation creates an environment in which people are more likely to use alone, without a partner monitoring them. The circumstances surrounding social isolation and lack of access to care, superimposed upon PPE shortages and budgetary shortages, pose unique challenges to HR operations during a global pandemic. When considering the impact SARS-CoV-2 has on New Mexico's communities, it is crucial to consider how operations like HR have been affected, making New Mexico's most vulnerable and isolated populations more susceptible to adverse outcomes.
Limitations to this study include a small sample size of 13 respondents representative of fty sites. The average of thirty eight public health o ces may have under or overestimated individual outcomes. The categorical survey questions created upper limits of data, and may have underestimated data, for example if a site had much higher than 51 clients, we were unable to demonstrate those nuances. Because of the unique demographics of New Mexico, these results may not be generalizable to other HR operations around the country. Lastly, each respondent was chosen within the HR site which may have negatively impacted the accuracy of data given in each survey.
Harm Reduction services are crucial in mitigating the personal and communal negative effects associated with SUD in the community, and are even more crucial in saving lives during times of increased stress . In order for HR service to function during times of public crisis and continue to serve our vulnerable communities struggling with SUD, there must be prior planning and preparation for such crises. As recommended by multiple agencies, stockpiling of PPE and other medical supplies should be adequate and maintained to address pandemic crises--in the case of HR sites, syringes especially should be stockpiled as this was the most commonly cited equipment shortage (Hashikuro & Kizu, 2009;Carias, et al. 2015). Further, a decrease in the overall burden to HR sites, i.e. decreasing the number of patients in need of such services, can reduce the impact pandemic and associated shortages have on the delivery of such essential services. Policies focused on increased funding for medication assisted treatment (MAT) clinics and the implementation of evidence-based interventions such as safe-injection sites can help communities become less dependent on harm reduction, decrease healthcare costs associated with SUD and comorbidities, and decrease the negative public health impacts on society ). This could be especially bene cial for New Mexico as increased funding could expand the reach of HR and MAT to our most remote areas.
More data should be collected to document the extent of effect stay at home orders and other Sars-CoV2 policies have had on patients with SUD. Research surveying MAT clinics and data collection from Emergency Departments may provide a more complete understanding of these effects and can guide further recommendations.

Conclusion
Harm Reduction sites provide essential, life-saving services to people struggling with substance use disorders while simultaneously decreasing adverse community effects of widespread substance use. During health crises, it is necessary to consider the preparedness of local infrastructures to not only support traditional healthcare operations but also extend to public health interventions serving vulnerable populations. New Mexico in particular, with high rates of OUD, alcoholism and rising hepatitis C infections in the context of extreme rurality and poverty, would bene t from policy supporting further protection and subsidy. Declarations 6.1 Ethics Approval and Consent to Participate: Ethics Approval Not Applicable.
The study did use a consent form, which was sent with the survey link, outlining the bene ts and risks of participating in the study. After reading the consent, participants had the choice to participate by clicking the survey link or declining participation [Please see attached].

Consent for Publication:
Not applicable.

Availability of Data and Materials:
The datasets generated during and/or analysed during the current study are available from the corresponding author on reasonable request.

Competing Interests:
The authors declare that they have no competing interests.