To prevent COVID-19, public health messaging is clear: avoid public places and stay six feet away from other people. But for people facing homelessness and living in a shelter setting or on the street, these practices are nearly impossible to maintain. For people who also struggle with substance use disorders, social distancing messages seem directly at odds with harm reduction recommendations that keep them safe from overdose. And social distancing messages don’t necessary address common substance use behaviors that increase the risk of COVID-19.
The fear of coronavirus among people experiencing addiction and homelessness in Boston is palpable. In shelters, the virus has the potential to spread like wildfire with life-threatening consequences. Adding to the intensifying stress, people are now largely cut off from in-person counseling, harm reduction services, and other social supports. For people with substance use disorder, it is a formula for increased relapses and overdoses. Difficulty accessing clean injection equipment could also drive a surge in new HIV infections.
Jessica Taylor, MD, medical director of Boston Medical Center’s Faster Paths to Treatment program, shares her concerns about people currently caught in the crossfire of separate epidemics, the unique risks they face under social distancing orders, and her hopes for innovative outreach that is emerging to support this community.
HealthCity: What risks do people with substance use disorder and homelessness face while the city is shut down to stop the spread of coronavirus?
Jessica Taylor, MD: Many recovery support services like behavioral health counseling and peer support groups are upended right now. We are circulating online resources, and luckily a lot of groups are offering virtual support meetings and contact with recovery coaches. But it’s a real change for a lot of our patients, and it’s a sudden loss of concrete support.
As we move toward an enforced social distancing approach across the country, we also worry that people could have their supply of substances interrupted. We worry that use becomes less safe when people experience withdrawal or when they can’t access their usual dealer and seek out a supply that they know less about – this puts them at high risk of overdose.
HC: Another major concern is an increase in HIV during the coronavirus pandemic. Why’s that?
JT: Before the COVID-19 outbreak, we were talking every day about the new HIV outbreak among people who inject drugs that’s happening in Boston right now. A lot of our energy and public health resources were being directed there. And now, of course, public health efforts are focused on COVID-19 prevention, as they should be. But I do worry that the COVID-19 pandemic will separate people who inject drugs from services that provide clean syringes and injection equipment. We could see increased sharing of injection equipment and a further rise in HIV infections.
"Before the COVID-19 outbreak, we were talking every day about the new HIV outbreak among people who inject drugs. I worry that the COVID-19 pandemic will separate people from services that provide clean syringes and injection equipment." Click To Tweet
HC: What unique considerations are needed to protect people who use drugs in the coronavirus pandemic?
JT: One challenge is that the public health messaging to stay socially distanced is really in direct conflict with the overdose prevention messaging that we’ve been giving people for many years — never use alone, use in a group, have someone close to you who can give you Narcan and call 911. We need to be thoughtful about how we apply social distancing messaging to patients who face significant risks from isolation. How can we keep you as safe as possible from COVID while making sure you are monitored in case of overdose?
Additionally, we need to talk to our patients about common behaviors that increase COVID-19 risk. For example sharing cigarettes or a pipe to smoke stimulants puts you at really high risk for transmitting COVID-19 because of close proximity to the other person and the potential to pass saliva and respiratory secretions.
Sharing cigarettes or a pipe to smoke stimulants puts you at really high risk for transmitting COVID-19 because of close proximity to the other person and the potential to pass saliva and respiratory secretions.
Boston Healthcare for the Homeless and the outreach teams at Project Trust, AHOPE, and the Engagement Center have all been leaders in this in the space. As providers, it’s important that we make sure we keep talking to patients about how to avoid overdose and prevent HIV and also give them the best information we have on how COVID-19 is spread and what changes they can make, even within the confines of unstable housing.
HC: How are these prevention messages getting out?
JT: Street-based outreach is a primary method right now. We are very fortunate to collaborate with outreach workers who have built a lot of trust among the community. Our patients have dealt with so much stigma from the healthcare system that as providers or public health experts or government officials, we often — and rightfully — don’t have the credibility with this population. So we are relying heavily on the leadership of outreach and harm reduction teams that have really been in the community doing good service and building bridges for a long time.
We are also focusing on prevention messages for the patients who do come through the doors. In Faster Paths, our low-barrier addiction bridge clinic, we are maintaining our usual business hours so that we can see the patients who walk in because they don’t have another way to get to us.
For those we can connect with by phone, we are offering to move as many new and follow-up visits as possible to telemedicine. With changes in state and federal regulations due to the coronavirus emergency, we are currently able to start and refill buprenorphine to our patients using telemedicine.
HC: Are there challenges to providing telemedicine to clients who are housing insecure?
JT: One concern that we’ve had with the overall move to telemedicine is that it risks exacerbating disparities for patients that are already at the highest risk – patients who don’t have a phone or a private place to have a call. They might be in a shelter, or on the street, or couch surfing. To maintain access for those patients, we’ve partnered with community organizations that already do street outreach and have set up a new pathway where our street outreach workers set up a video conference or telephone call between their device and an addiction specialist.