This paper has presented findings from a co-produced, peer-led research project that investigated the impact of the COVID-19 pandemic on people with substance misuse problems. Drawing on qualitative ‘survey interviews’ with a sample of 202 substance misuse service users, the study examined the impact of the pandemic on their drug and alcohol use, their personal lives, and their substance misuse treatment experiences.
While there is a growing body of research investigating the impact of the COVID-19 pandemic on substance misuse and related behaviours, our literature searches identified only one UK-based study that had used a peer-led approach and incorporated people with lived experience into the research process (Adams et al., 2022). This was not entirely unexpected given that in substance use research generally, few studies have embodied the principles of co-production and relatively little co-produced research has been published (Cairns and Nicholls, 2018). Our study therefore makes an important contribution to ‘an emerging field’ that recognises (a) the right of ‘patients’ (or people with lived/living experience of substance misuse problems) to be part of research aimed at their wellbeing, and (b) the critical value of their insights and experiences (Cairns and Nicholls, 2018).
The peer-led approach was beneficial in many respects including the recruitment of a large sample of service users. The peer researchers reported improvements in their self-esteem and self-confidence as a result of their involvement and service users appeared to benefit from the opportunity to discuss their problems with someone with lived experience of similar challenges. Furthermore, collaborating with substance misuse services facilitated the early and wide dissemination of findings through an infographic-style online report (and subsequently a webinar), which translated the results into visual, easily understood information suitable for a wide audience (Olfert et al., 2019; Barod, 2021).
However, our peer-led approach was not without its limitations. As novice researchers, the peers were unfamiliar with the demands of empirical research, which is likely to have contributed to inconsistences in data-recording practices and more missing data than we had anticipated. These limitations might be considered a small price to pay for the many benefits that co-production brings. Indeed, the ‘dark side’ of co-production is to some extent inevitable and has been described as part of the ‘rub’ of ‘managing the conflicting demands of empirical research with effective co-production methodologies’ (Oliver et al., 2019, p.1.; Clayson et al., 2018, p.56).
While the main aim of this study was to ‘learn lessons’ for substance misuse services for any future lockdowns or global crises, the study also provided an opportunity to learn lessons for the co-production of substance use research. Our experiences suggest that it would be helpful to offer more intensive training to peer researchers and to thoroughly pilot both the data collection process and the analysis. The co-creation of research outputs that meet the needs of each collaborating partner is also recommended. Journal articles are not always the best vehicle for generating impact outside of the Academy and the lengthy academic peer-review process can delay the publication of important findings (Oliver, Kothari and Mays, 2019). Co-creating outputs in accessible formats and disseminating them through both academic and non-academic platforms could therefore help to speed up the dissemination process and maximise impact.
Consistent with studies of similar populations in the UK, the service users in this study responded to the pandemic and adapted to the lockdown environment in a variety of ways (Higgins et al., 2020; Schofield et al., 2022; Seddon et al., 2021). While some maintained the status quo making little, if any, changes to their patterns of drug and alcohol use, others changed the frequency of their use, the quantities consumed and/or the types of substance that they used. Varied responses to the pandemic were also reported in other aspects of the service users’ personal lives as well as their treatment experiences, highlighting the individualised nature of the impact of the pandemic.
The diverse range of responses reported by the service users in our study, support Nordgren and Richert’s (2022) assertion that people who use drugs are not a homogenous group. Rather, they are a group of individuals who respond and adapt to crises and events in different ways depending on a wide range of factors. Understanding what these factors are and how they interact to escalate or reduce the risk of harm is therefore an important goal if lessons are to be learned for the future.
Previous research suggests that vulnerability to drug-related harm is strongly associated with the social or physical spaces in which drugs are used (Rhodes, 2002, 2009). Within these spaces (or risk environments) it is argued that a variety of physical, social, economic, and policy-related factors interact at different levels to shape the drug-using environment. While some researchers have focused on how these factors work to escalate the risk of harm (Rhodes, 2002), others have considered how they can decrease exposure to drug-related harm and shape an ‘enabling’ environment (Duff, 2010).
Recent research drawing on the perspective of social workers in Sweden identified the COVID-19 virus as a ‘new’ risk environment factor that increased vulnerability to drug-related harm among some people who use drugs (Nordgren and Richert, 2022). However, the virus was also noted to facilitate aspects of the enabling environment thereby reducing the risk of harm among some members of this population. The results of our study support both of these conclusions.
First, the pandemic and associated macro-level lockdown measures impacted at the institutional level by forcing services and support groups to shift away from face-to-face delivery to online and telephone formats. For some service users, this affected their ‘risk environment’ and increased their vulnerability by restricting their access to activities and support systems that had previously helped them to cope with substance misuse-related problems. For others, such as those living in rural communities and those with social anxiety problems, the shift to remote forms of delivery had an ‘enabling’, harm-reducing effect in allowing them to access support more easily, cheaply and comfortably than previously (see also Adams et al., 2022).
Second, the macro-level lockdown measures resulted in significant changes to the prescription and distribution of opioid substitution treatment (OST). This included the roll-out of long-acting, injectable buprenorphine (Buvidal) and the wider provision of take-out supplies of other forms of OST. For some service users, the provision of take-out supplies influenced their enabling environments through an increased sense of empowerment and responsibility (see also Schofield et al., 2022; Kesten et al., 2021). The impact of these changes on the risk environment was less obvious. However, some service users expressed frustration at not being prescribed Buvidal while others reported difficulties and delays in accessing scripts from community pharmacies, which could have led to the onset of painful withdrawal symptoms and relapse.
Third, the macro-level lockdown measures on some occasions acted as a risk-generating factor directly on service users without the intermediary effect of institutional level factors. Indeed, for some service users relapse incidents and problems in their personal lives were triggered by the boredom, anxiety, and loneliness of lockdown. For others, however, the lockdown measures had an enabling, harm-reducing effect by providing greater opportunities for exercise, outdoor activities and spending time with family members. In some cases, lockdown led service users to cut-down their substance use.
Fourth, the lockdown measures impacted on local drug markets, which in turn affected drug purchasing patterns. For some, the changes altered the ‘enabling’ environment through shifts to less harmful behaviours such as purchasing drugs through friends (hence reducing their risks of being apprehended by the police) or limiting their use to legally prescribed (unadulterated) medication. For others though, the changes affected the ‘risk’ environment as they began to purchase drugs more frequently, in larger quantities and personally rather than through friends thereby increasing their risk of arrest, robbery and increased use.
Finally, Welsh Government’s harm reduction approach has for many years helped to shape an enabling environment through the distribution of naloxone (a life-saving, overdose-reversing drug) to people at risk of an opioid overdose. Our findings highlight that this enabling environment was negatively affected by the policies imposed during the pandemic. Due to the social distancing restrictions and the lockdown measures, only a small number of service users reported accessing naloxone during lockdown. This meant that important opportunities for harm reduction were lost and that service users (and those around them) were at an increased risk of a fatal overdose (see also Whitfield et al., 2020).