Two focus group discussions were conducted, including one large forum consisting of 35 participants convened through Public Health England and another consisting of five participants. This was followed by six semi-structured in-depth interviews conducted, giving a total of 46 participants. Focus groups lasted approximately 70 minutes on average and in-depth interviews lasted 30 minutes. Participants represented various organisations including alchol and drug recovery services, community pharmacies and voluntary sector. A total of 10 themes emerged from the data (Table 1).
Table 1
Ten themes identified during thematic analysis
| Themes Identified from Focus Groups/Interviews |
| 1. General Experiences of Service Provisions During the COVID-19 Pandemic |
| 2. Protecting the Most Vulnerable |
| 3. Changes to Interprofessional and Service Provider/User Communication |
| 4. Patient-Provider Relationships During The Pandemic |
| 5. Psychological Impact of COVID-19 on Service Providers and Service Users |
| 6. Resource and Service Availability |
| 7. Organisational Challenges |
| 8. Preserving the Quality of Care |
| 9. Self-Reported Trend in Substance Use During the Pandemic |
| 10. Learning from the Pandemic |
General Experiences of Service Provisions During the COVID-19 Pandemic
During the initial outbreak of the pandemic, immediate concerns as described by the participants related to the continuation of services and monitoring vulnerable individuals whilst following government guidelines. Due to the national lockdown, the overnight closure, and reductions in a service capacity, there was an urgent need to adapt how in-person interventions were delivered. Participants spoke of service users offered reduced supervision from D&A services during the COVID-19 pandemic. For example, adolescent service users were monitored less frequently, which was attributed partially to the closure of schools and other organisations that liaise with D&A services. Community pharmacies dispensed several days of supply of adult opioid substitution therapy (OST) i.e. methadone or buprenorphine, at once, replacing daily supervised consumption.
“We reduced the supervision to probably once, twice or three times a week” (NHS Foundation Trust Regional Manager)
“Taking home a month’s worth from a pharmacy. That was reduced to two weeks” (Addiction Service Lead Pharmacist)
Adaptations also included substituting methadone with buprenorphine due to reduced monitoring capacity.
“We didn’t initiate anyone on methadone, […] only initiated using buprenorphine. Because we weren’t doing any urine testing, there was a risk of overdose” (NHS Foundation Trust Regional Manager)
However, some participants described that the pandemic brought opportunities to offer outreach services.
“We just did a lot of outreaches we even took on nursing services onto the streets” (Drug misuse and needle-exchange service employee)
Protecting the most vulnerable
All participants highlighted the importance of initially risk assessing with a ‘traffic light system’ to distinguish the most vulnerable service users and assess individual needs to adjust the way in which support was offered. Participants emphasised that although face-to-face contact was minimised, service users deemed to be of higher demand were offered more opportunities for face-to-face contacts.
“In the beginning we tried to maintain contact with people in at least the proportion of contacts that we had prior to lock down, some actually we tried to have more contact with, if our assessment was there are particular risk issues or particular needs” (D&A Services Provision Manager)
Many providers described increased vulnerabilities amongst the most disadvantaged, including those relying on street begging, sex workers, as the pandemic took away their livelihood. Other challenges that complicated service delivery included a reported increase in domestic abuse.
Changes to Interprofessional and Service Provider/User Communication
All participants reported that telemedicine was significantly expanded following the outbreak of COVID-19. While many described that remote communications improved professional efficiency, some participants spoke of the drawbacks of telehealth and digital forms of D&A services, citing staff computer shortages and an inability to conduct physical health examinations thoroughly. Moreover, some participants found telemedicine to negatively-impact service provider/user communication, crediting a loss of nonverbal cues and difficulty building relationships with new service users.
“If you’re unable to develop that relationship to its full extent because you’re not interacting with people in the same way, then it’s going to suffer.” (Youth D&A Misuse Service Manager)
In contrast, participants described that stable service users found remote consultations convenient. This was partially attributed to boredom and isolation due to restrictions on socialisation during lockdown periods. On the other hand, non-access to digital devices would make some service users disadvantaged. Some providers described maintaining face-to-face services to those without such access.
Those that were really vulnerable were extremely vulnerable in that time and that divide between them was massive. So yeah, we just prioritized risk. Those that were most at risk had the most face to face contacts and those that were able to utilize the digital offer and we sort of use that for those that could. (D&A recovery worker)
Digital appointments, particularly group sessions offered greater opportunity to develop peer network.
Just being the importance of providing people the opportunity to connect with the right kind of support but also like minded peers so that they can, you know, recovered together. I think without peer support I mean the greatest success that we've had during the pandemic has been through our online group support where people are meeting on a daily basis and supporting each other and maintaining connections that they've. (Recovery services manager, D&A service)
In addition, digital service provisions reduced the waiting time for appointments. In addition, particularly for counselling services and psychological therapies such as cognitive behavioural therapy (CBT), outcomes were deemed to have been improved, and recovery rates increased.
Patient provider relationships during the pandemic
All participants who provided OST spoke of service provider/user trust improving following the suspension of supervised consumption of opioid substitution therapy. In addition, many service users were deemed to have felt empowered to take control of their treatment, adhering to their medication regimen.
“They […] showed us that they were trustworthy […] they were able to manage the bits we were worried about around their […] medications.” (Drug misuse and needle-exchange service employee)
Improved interprofessional collaboration between D&A and other services such as homelessness service providers were also described. Several subjects reported that accessibility of D&A services to homeless people improved during lockdowns, citing that secure accommodation provisions facilitated access to D&A services.
“We could look back and think why didn’t we do that, sooner, why did it take a pandemic, to get people housed, fed, clothed, nursing care delivered to them and a degree of stability, which allowed people to stick on scripts or even detox from that alcohol” (D&A Services Provision Manager)
Psychological Impact of COVID-19 on Service Providers and Service Users
Most participants described increased personal and work-related stress during the COVID-19 pandemic, citing unwell family members, self-isolation-related staff shortages, and frustration of service users.
“Staff were very pressured because a lot of them had to shield themselves, and patients were a bit frustrated” (Addiction Service Lead Pharmacist)
Some participants reported apprehension about non-adherence to treatment, overdoses and deaths due to reduced supervision and feeling depressed and isolated during lockdown periods.
“I went a bit wonky at the beginning of this year, and when I look back on it, I think it was depression” (Youth D&A Misuse Service Manager)
Participants also described a rise in anxiety and dread amongst service users. Some service providers saw an increase in the number of referrals for alcohol. Many individuals were found to have relapsed during the pandemic outbreak, particularly for alcohol, as isolation and social deprivation resulting from lockdown may have encouraged substance and alcohol misuse as a coping mechanism while others stockpiled medicines.
“People were stocking up on medications because they were worried about […] what lockdown one’s going to be like.” (D&A Misuse Service Regional Manager)
Conversely, other participants explained how school closures and restrictions on socialisation reduced peer pressure for some adolescent service users, resulting in reduced substance use.
“In a friendship group where your friends are offering it you, where your friends are… However, in COVID, that isn’t the thing so, if you never started it outside of COVID, and then COVID happens, you’re less likely to be in that environment where you know where to get it.” (Youth D&A misuse service employee)
Some participants however explained that engagement with young people diminished as majority of young people didn’t have a private, safe, and secure environment in which to participate in remote online telephone calls
Resource and Service Availability
Most participants spoke of insufficient resources citing understaffing and lack of available personal protective equipment (PPE), particularly during the first wave of the pandemic.
“It took us a month or so before we got the proper PPE in place.” (NHS Foundation Trust Regional Manager)
Several participants also explained how unfilled staff shortages led to suspension of services, such as supervised consumption and screening, treatment, and vaccination of hepatitis infection.
“Hepatitis screening, hepatitis C treatment, hep B vaccinations, […] was put on hold because of this. Because we were not able to see people face-to-face” (NHS Foundation Trust Regional Manager)
Similarly, another participant reported: “We stopped the supervised diamorphine” (Addiction Service Lead Pharmacist)
Many blamed the unpreparedness of D&A services on service providers not making contingency plans seriously prior to the outbreak of COVID-19.
“I don’t think we ever rehearsed our contingency plans” (Addiction Service Lead Pharmacist)
Adolescent safeguarding provisions were also reported to have been affected, citing school closures reducing interprofessional dialogue between school-based and D&A services.
“It’s a bit more tricky to talk to professionals about it because it’s not just like, you know, you can talk to a teacher after a session and be like ‘how has this kid been doing in school.” (Youth D&A misuse service employee)
Participants noted that there were increased queues in pharmacies contributed by increased demand for prescription services which was deemed to have created enormous pressure on pharmacies to have the capacity to continue daily supervised consumption.
“Queues of pharmacies for everyone, and that made it really difficult if you were supposed to be collecting a script daily, submitted by yourself, in a queue for hours on end.” (D&A Service Provision Manager)
Services also had to introduce home delivery service to users on daily OST who had to self-isolate during the pandemic and one participant suggested this was complicated to set up in terms of permissions and authority to carry medication on behalf of service users. Supervised consumption regimes were adjusted to weekly or even monthly prescriptions instead of daily and so individuals were now responsible for a larger supply of medication and one participant noted;
“This created a little bit of anxiety for us as an organisation because we were concerned this would lead to more overdose or deaths” (D&A Service Provider)
Organizational challenges
Participants noted staff shortages as a particular challenge as demand was surpassing resources available at the time. Participants described the difficulties in recruiting new team members and pressures of redeploying and redirecting staff to other areas or services that had been particularly impacted by COVID-19.
“That the main issue was, I guess, the difference between delivering kind of supportive services via phone line and by phones than face to face, you know and very quickly, we started recognizing the need to re-train our staff.” (D&A Services Provision Manager)
The pandemic also disrupted communication within and between other organisations as some participants endured difficulties adapting to contacting other professionals on online platforms. One participant explained that communicating with pharmacies became challenging as pharmacies were overloaded and exceptionally busy during the pandemic. This became a concern as information on safely reducing supervision (as described above) and legalities needed to be provided to pharmacies. However, there were many barriers to communication, such as changes in contact information as many physical facilities were shit and services moved to new temporary sites.
Preserving the Quality of Care
Participants spoke of different ways through which they had adapted service delivery. While some adaptations were deemed positive (e.g. greater engagement with established service users), others reported challenges in ensuring the quality of care. For example, many adolescent service providers found it difficult to make their assessments over remote consultation methods. They also described that young people had more difficulty engaging with services from their houses as the phone line wasn’t always private.
“We sort of half-expected that young people would want to engage like this, kind of video call, and that would help to pick up on some of that stuff. Nevertheless, actually, what we found, […] was that young people didn’t want that. They wanted phone interventions” (Youth D&A Misuse Service Manager)
Most participants spoke of prioritising risk assessments, emphasising their importance in preserving service user safety.
Self-reported trend in substance use during the pandemic
Most participants described noticing increases in depressant and sedative use, with Xanax (alprazolam) use increasing amongst adolescent service users, while an increase in alcohol consumption was most prominent amongst adults.
“Cannabis stinks the home. If parents are not down with the weed, […] then they’re gonna get found out, you know, so why not take a couple of Xanax (alprazolam) instead.” (Youth D&A misuse service employee)
It was postulated that the popularity of sedatives rose due to boredom and inaccessibility to mental health services during the lockdown.
“Being isolated, and their way of coping with boredom was drinking alcohol and also mental health-wise, people were sort of like er medicating their mental health with, mainly alcohol” (D&A Misuse Service Regional Manager)
Opiate use was deemed to have reduced attributed to supply issues and increasing street prices.
“The amounts of […] illicit drugs on the streets actually decreased. And I think the prices went up as well because it’s a supply and demand market.” (D&A Misuse Service Regional Manager)
Learnings From The Pandemic
All participants recognised the benefits of risk assessing service users using a ‘traffic light system’ and providing care based on each individual’s risk. This is a procedure that participants deemed was likely to continue post-pandemic.
“Think that we've got a body of experience of making those risk assessments and it's going to be informed by things that we learned during the pandemic” (D&A Services Provision Manager)
Most participants agreed telephone and online interventions may be continued for more stable individuals alongside face-to-face as a ‘blended approach’ as it worked well for both service users and providers in terms of efficiency and ease of accessibility.
Similarly, with individuals on OST who had been trusted with a larger supply of medication to take unsupervised, participants explained this was a positive to come from the pandemic as many enjoyed the responsibility and trust granted to them.
“Some people kind of I think thrived in the in the pandemic situation you know, actually, you know, took ownership of some of the stuff that they weren't perhaps taking as much control of beforehand and showed us that they were trustworthy, that they were reliable” (D&A Services Provision Manager)
Despite barriers to communication within organisations, several advantages of virtual communication were described, particularly for larger organisations, as it made organising governance and senior management meetings easier.
Participants suggested the importance of having contingency plans in the event of future pandemics. Ensuring staff were correctly trained for such events and developing contingency plans outlining arrangements with various service providers, including community pharmacies, would provide a structured approach. However, most participants noted that in the face of the unprecedented events that followed the pandemic, services managed to continue and adapt mostly guided by local arrangements and agreements in place.