Pandemic impacts on the lives of iOAT clients
Economic (in)stability
Given the potential economic impacts of the pandemic, participants were asked whether their opportunities for income generation had changed and how these changes affected their financial stability. Most participants were receiving some form of government income assistance and noted that in response to the pandemic, the government had slightly increased this monthly rate. For some participants, this marginally higher income, when combined with reduced opportunity for spending due to pandemic restrictions, resulted in greater economic stability. For others, this additional increase in assistance only helped to offset the rising price of consumer goods amid pandemic supply chain interruptions. While few participants had full-time employment, some participants were engaged in informal or part-time work—opportunities that were generally reduced during the pandemic. As participant #17 remarked, “I’m having to stay home and not be on the street doing anything, I guess I am losing money.” For this participant and others, opportunities for odd jobs or street-based work (e.g., reselling goods; panhandling; informal recycling) were limited, but the informal nature of this work also precluded them from applying for pandemic relief benefits, such as the $2000 Canada Emergency Response Benefit (CERB). In several interviews, participants raised concerns about CERB recipients they perceived to be ineligible, and expressed fears about the consequences of an influx of money on their community (i.e., the “cheque effect”; Otterstatter et al., 2016; Richardson et al., 2021). As participant #2 explained, “people are getting thousands and thousands of dollars get handed over to them through the government and people are just getting crazy.” For participant #7, who sold drugs to generate income, more disposable income in the community meant that he also received additional money: “I sell dope and I think it’s funny but I’ve seen more money now that I had before. Is it ‘cause everybody is getting more money? I don’t know, but I can’t complain personally.” Participant #9 felt this influx of money had shifted community dynamics and triggered negative emotions for him when traveling Downtown and to the clinic:
I don’t like to go down just for visits, because I do find that the temptation a bit unwieldy sometimes…People discovered this [Canadian Revenue Agency] benefit that everybody’s been getting…People have been living high on the hog Downtown in a way…It’s going to be really bad if people have to pay all that stuff back, right. There’s storm coming where that’s concerned. But anyway, no I don’t go Downtown—just to visit, only for when I need to.
As an iOAT client and employee, participant #18 explained how drastic fluctuations in income could impact clinic retention: “some people don’t come anymore. There’s a number of reasons for that and I couldn’t really nail them down, apart from the fact that there was money available for people and a lot of people applied for it and got it, so probably that would impact the numbers.” In other words, participant #18 speculated that iOAT clients who received pandemic relief funds may have spent their additional income on street-based drug supply, rather than visiting the clinic. While most participants did not explicitly point to a direct connection between their economic stability and retention in iOAT, the pandemic and associated government response had indirect impacts by generating economic uncertainty and by facilitating dramatic fluctuations in the local economy in which participants lived and worked.
Physical health
While the COVID-19 virus poses a health threat to everyone, those who are immunocompromised or have significant health issues face even greater health risks. IOAT clients emphasized that their underlying health problems, including HIV, Hepatitis C, cellulitis, cancer, and respiratory conditions, increased their risk of severe outcomes from COVID-19. Participant #12 expressed a common sentiment among participants: “I’m 66 years old, I have COPD and basically it’s end of story if I come in with [COVID-19]. I’m pretty much guaranteed to be a dead man.” For some participants, the increased risk of severe COVID-19 outcomes deterred them from seeking healthcare when needed. Participant #11 recounted her situation: “I thought I was having a heart attack ‘cause my arm went numb and I was getting chest pain, but I was so scared of going into emergency because that’s where COVID-19 [is].” Participant #14 described a similar circumstance: “I was terrified, I didn’t even want to come [to the hospital]. I almost made myself get sicker before not coming, because I was so terrified to come to the hospital because they were saying that’s how you catch COVID, in the areas like the hospital.” This reluctance to seek medical care was particularly salient at the start of the pandemic, amidst the highest levels of uncertainty and closures or restrictions on medical services, but anxieties around COVID-19 persisted throughout the duration of the study, suggesting enduring unmet treatment needs among clients.
These perceptions of heightened COVID-19 risk could also deter participants from accessing the iOAT clinic because of the perceived risk of exposure while in transit or within the clinic. Participant #15 remarked on her desire to switch treatment: “It’s way more stressful than before because I’ve got COPD, I have asthma so it’s—I honestly gotten terribly [scared] to leave the house…I’ve been having panic attacks. I'd like to actually switch to having my dose delivered from the clinic because I can’t handle the stress of coming up here.” For some participants, the risk of COVID-19 exposure was enough to prompt them to reduce the number of times they attended the clinic. Participant #4 explained why he reduced his iOAT visits to once per day, “Because of the pandemic. That as well as weather.” At the time of his last interview, he had not received a take-home dose and because of that, he “still wake[s] up sick most days,” and compensates with unregulated opioids. Some participants opted to change their treatment plan entirely due to the risk of exposure to COVID-19. As participant #10 explained, “I’m staying home as opposed to going to get my shot. I went on methadone until this is over. If I got sick, I don’t think that would be very good for me. I have COPD and other underlying problems, that wouldn’t be good if I got COVID.” As these perspectives highlight, many iOAT clients had to weigh the risk of exposure to COVID-19 against the risks of altering their treatment plan, which for some participants, like participant #4, meant unfulfilled treatment needs and subsequent exposure to unregulated opioids.
In addition to physical health risks, some iOAT clients experienced physical barriers to accessing services during the early pandemic response. Pandemic policies forced changes in occupancy for retail and health services, requiring people to wait in long lines outdoors. IOAT clients with physical disabilities remarked on how these changes impacted the services they were willing or able to access. Participant #13 described her situation: “I miss the food banks mostly. And in grocery stores you can’t even go in them really…Seems everywhere you go, you stand in line. …It’s difficult. I can’t do anything out here. I’m in a scooter too so that makes it even worse.” Policy changes around occupancy guidelines extended to the iOAT clinic setting, where clients had to wait outside before they could access their medication. For people with mobility issues, this waiting period could pose a challenge. As participant #2 explained: “Being a disabled person, I find it a little difficult sometimes to stand and the fact that [the clinic] is only allowed 8 clients in at any time, that’s added time to the wait.” Even when clients were able to stand in line outside of the clinic, some felt uneasy being in close proximity to others in a pandemic. Participant #3 explained the process of lining up to enter the clinic:
They all crowd around the door and want to be seen by the nurse, and [the nurse] writes down the names. So, I didn’t want to do that. I wanted to do the safe distance thing and so I keep away. And I wouldn’t get—like I missed two times. I’d have to phone them and tell them that I’m out here. I’m over about ten feet away from the crowd and then they would put me down [on the list].
Though iOAT clinic staff accommodated participant #3’s request for distance while waiting, pandemic conditions created physical challenges for iOAT clients and consequently, a physical barrier to treatment.
Mental health
In addition to anxiety about physical health risks, the pandemic negatively impacted iOAT clients’ mental health, largely by severing their social ties and reducing social support. In accordance with public health guidelines, many iOAT clients opted to reduce the number of social contacts or were forced to through visitor restrictions imposed by their social or supportive housing units. Without regular interaction from friends or family, participants described feeling bored or lonely, like participant #14, who expressed, “I don’t spend my time with a lot of people but since the COVID virus, I’ve been extremely lonely. It’s extremely hard to be home all alone all the time. You know, my doctor advised me to stay home as much as I could and to just stay away from everybody and just be home, that’s extremely hard.” For iOAT clients, feelings of loneliness and uncertainty around the pandemic were heightened by the concurrent overdose crisis facing their community. As participant #2 stated, “fentanyl is a pandemic and it's not being addressed quick enough.” Participant #8 described how these dual crises intensified her feelings of loneliness:
I used to have a lot of friends down here and now I don’t and I’m really lonely. I don’t really feel like befriending any more people down here because they’re just going to die or they’re going to do something to break my heart. I just don’t feel like making more friends. In that case, why be here? So I can sit here in my isolation, even without COVID? Like sleep and read my life away?
As participant #8 highlights, the isolating nature of the pandemic could amplify the mental health impacts of the overdose crisis, prompting more intense feelings of grief, loneliness, and worry. However, it is important to acknowledge the continuity of iOAT services during the pandemic and the clinic’s role in supporting clients’ health, as echoed by participant #7: “I say the clinic’s still open and that basically is my number one concern in my life. As long as that place stays open, I’ll stay alive, I know that.”
While participants were grateful for iOAT and the clinic, the mental health challenges experienced by iOAT clients during the pandemic could indirectly impact their treatment experiences. When participant #5 couldn’t see her boyfriend, who was also an iOAT client, she felt “lonely and isolated and angry” and that “everything came to a halt when I couldn’t see him,” and she stopped attending clinic altogether. As time passed, participant #5 was able to see her boyfriend again: “he came back and got me and now we’re staying together again and things are better, but if it wasn’t for that, I wouldn’t have come back [to the clinic].” While participant #5 and other iOAT clients were eventually able to reconnect with local friends and family, a few participants remarked on how the pandemic prompted a desire to connect with family who lived further away, but that they felt unable to deviate from the clinic schedule. Participant #8 described her challenges around the routine:
I’ve been there for a long time and it’s just—I think I just need a break. I’ve gotten to a point where it’s too monotonous, too repetitive, too much of my time. I can’t do anything else. [There’s] no room to do anything else in the day, basically. I can’t go to [name of town] to go see my mom. By the time I get out there, I have to turn around and come back. I get to visit for an hour or two.
As a long-term client, participant #8 felt treatment was effective, but that the rigid schedule had a social cost, which was made clear in the pandemic. Taken together, interview data underscores that in addition to the general anxiety around the threat of COVID-19, iOAT clients were simultaneously facing rising rates of overdose in their community, disrupted social ties within their neighbourhood, and the constraints of a strict treatment regimen—all of which had bearing upon their mental health.
Pandemic Impacts On Ioat Treatment Provision
As the iOAT clinic adapted to COVID-19 protocols, the most noteworthy changes for clients were the reduced clinic occupancy and wait times for entry. Some clients found it challenging to schedule their day around a clinic visit, arriving on time only to wait in line. Participant #1 recalls, “it’s a lot of chaos coming into the clinic every day because only certain amount of people [are allowed in] and sometimes I’d be dope sick and I just really didn’t wanna deal with people’s shit so I would just leave and then go buy dope and not go get my shot, which is not good at all.” For participants experiencing dope sickness or other obligations, these delays could be enough to deter participants from accessing treatment. Once inside the clinic, however, some participants were pleased with the new procedures, like when the post-medication assessment period was reduced from 15 minutes to 5 minutes, to reduce risk of COVID-19 exposure. Participant #7 described this streamlined process: “I go in, sanitize my hands, they ask some questions, check-up, get meds, get my shot, wait for checkup and leave—it’s beautiful. I mean, 15 minutes, tops.” However, in trading the more relaxed clinic routines for efficiency, clients also observed that the general atmosphere had shifted at the clinic. Participant #17 spoke on the drawbacks of forgoing time in the post-assessment waiting room: “For some people, they don’t have a place to sit and relax and enjoy their meal or their coffee in the morning, or any time of the day. So, when they go in there, they can’t sit there after they get their shot and enjoy their meal, or their beverage.” Similarly, participant #8 described the clinic as “a lot more cold and a lot more—almost like a hospital ward.” Several clients also remarked on the closure of the clinic restroom, in part, to alleviate the burden of cleaning and monitoring by overextended staff. However, the loss of access to a clean restroom was noteworthy, especially for clients without housing. Participant #18 described this challenge for unhoused clients: “for people living outside, there are very few [restrooms] that are open. Most of them are packed, locked up, and not available to anybody and that’s not good for people.” While changes to clinic processes ensured that all clients could receive treatment amidst pandemic restrictions, the increased efficiency also meant the sacrifice of small comforts that drew clients to the clinic.
Changes in iOAT clinic processes also had consequences for the social dynamics within the clinic. Several participants described the clinic as a source of social engagement and community before the pandemic. Participant #14 expressed this sentiment: “I feel like I’m part of iOAT and I feel like they’re my family.” Yet, new pandemic protocols meant clients spent less time in clinic and more physically distanced, effectively reducing social engagement. Participant #8 described her experience with the changing social dynamic: “Everybody is distanced socially from people, [the clinic] doesn’t seem as close knit as it used to be. Pretty sad because it was pretty much the only place I feel like I could go to get any kind of experience with other people.” One clinic nurse (nurse #1) recalled similar feedback from a recent client survey regarding a new proposed clinic site:
When we did some client surveys about the new site, one of the big things people are asking for is a space for somebody could sit down for a few minutes or just hang out and review a magazine or whatever…And that’s something that I’ve heard as well, that we’re missing that kind of sense of community and I think it’s maybe not been said, but it is kind of tough cause all of our staff are wearing masks so we’re kind of losing that personal touch as well.
In addition to social engagements with friends and family outside the clinic, these perspectives highlight how the pandemic and related policies could shift dynamics within the clinic and compromise the long-standing social relationships among iOAT clients and staff.
New Opportunities In Ioat Treatment Provision
While the pandemic restricted clinic processes in some ways, it also accelerated the development of more flexible medication guidelines, in which clients had more autonomy around their health and medication regimen. To reduce iOAT clients’ health risks during the pandemic, providers worked with eligible clients to devise more flexible treatment plans, such as mixed treatment models, where clients could receive one injectable dose at the clinic and one take-home dose of oral medication (e.g., slow-release oral morphine; hydromorphone). Participant #11 recalled how she had been taking oral medications for over a year and when the pandemic began, staff reached out to her about transitioning to home delivery of medication (i.e., slow-release oral morphine). She had severe emphysema and was worried about going to the clinic but felt relieved when offered delivery: “The fact that I was given the opportunity to self-isolate and still be able to get what I need to keep me well is amazing. I really have to give the highest regards to the program…it’s life-changing.” Other clients were able to get longer prescriptions so they could reduce the frequency of clinic visits. Participant #9 was living in a different part of the city and felt that visiting Downtown so often was emotionally and physically difficult. However, during the pandemic, in response to his doctor increasing his prescription length, he remarked: “I was pretty happy about that…As much as I might miss the people [at clinic], I don’t like the idea of going down.” The opportunity for more flexible care prompted clients and staff to reimagine the possibilities for iOAT, with the hope that this flexibility would endure after the pandemic. When asked about desired changes for iOAT treatment, participant #2 responded, “It would be so much easier for me if I could get a morning carry shot, then I could go off to work. I mean, I’ve got to go to three places before I can even go to work. And by the end of the day, I've done that three times and it takes a big chunk of your day.” One clinic nurse (nurse #1) explained the novelty of some of these changes:
With iOAT being such a specialized service and kind of essential service for people, we’ve had to really modify all of our policies and procedures. Almost every aspect of the clinic has kind of adjusted... One of the new things that we’re doing is we’re actually outreaching DAM [diacetylmorphine] to clients who are isolating for COVID-19. So that’s a big, big, big change. We’ve never been able to take DAM off-site to somebody before.
As this iOAT nurse highlights, new procedures meant that clients with COVID-19 or isolating due to exposure were able to receive their medication safely outside of the clinic. While this nurse later acknowledged such personalized interventions may not be scalable, interview participants felt the flexibility to meet clients’ individual needs and have autonomy over their medication regimen was a critical characteristic of the program and hoped these changes would endure.
In addition to facilitating more patient-centered care, the pandemic highlighted important moments of connection and communication of health information between iOAT clients and staff. Participants felt connecting with staff at the clinic was a beneficial part of their treatment routine and this interaction seemed to provide a sense of community and stability amidst pandemic uncertainty. Participant #1 described her experience with staff: “when I come to the clinic, they say hi to me, ‘how are you?’ If they notice that I’m acting strange or not in the best mood, they come and ask me how I am and I can tell they actually care. And then when…shitty stuff goes on for me, sometimes they go out of their way and help me out.” In addition to emotional support, participants highlighted the role of iOAT staff in providing relevant information related to COVID-19 as well as in helping clients reduce their health risks. Participant #15 observed, “the place is being kept spotless and everybody—they're given the hand sanitizer at the door and making people wear masks and what have you. I think they’re doing everything they can do.” Clinic staff were even able to facilitate vaccination for clients who were medically vulnerable and thus prioritized in the province’s vaccine rollout. Participant #16 recalled the phone call that he and his partner received from clinic staff:
They said basically like ‘we’ve got [the vaccine], you guys should get up here.’ [My partner] and I looked at each other and said, ‘let’s get our ass up there.’ We got ready in about 15 minutes. Got on the bus got up there about like 25 minutes later. That was just good luck. It was one of the nurses in one of the other programs, and they recognized [my partner’s] name because she had COPD.
Though not all clients had received a vaccine at the time of interview, iOAT staff may have encouraged vaccine uptake, by directing clients to vaccination sites or by sharing their own vaccine experiences. In sharing his vaccine perspective, participant #9 remarked, “I’d be willing to use a vaccine if it meant giving me more freedom to move about in the world. A lot of doctors said it was safe, I trust them.” Like participant #9, many of the clients trusted the medical opinions of clinic staff, highlighting how iOAT treatment engagement could be an effective pathway for communication about the COVID-19 pandemic.