Overview
The Manitoba Harm Reduction Network (MHRN) coordinates and supports harm reduction – programs and practices that aim to minimize the negative effects of substances on the people who use them – in different areas of Manitoba. MHRN has 11 regional networks and 12 advisory groups of staff and peers (people with lived experience of substance use). In the summer of 2021, the National Collaborating Centre for Infectious Diseases (NCCID) partnered with the MHRN to evaluate harm reduction services in Manitoba during the COVID-19 pandemic. The evaluation was done to understand how the pandemic has affected people who use substances (PWUS). It was also done to find out how harm reduction agencies, and those who work in public health, can better support PWUS. Over three months, MHRN staff and PWUS from all 11 regional networks talked about their experiences. A Knowledge Keeper provided support to participants and her own insight as a community leader. The complete findings of the evaluation are available on the NCCID website and contain a fuller discussion of how COVID-19 has affected people who use substances in Manitoba.
In this document, we provide a summary of key findings from the evaluation. Findings include recommendations for changes to programs and practices that can be made by harm reduction service providers, clinics, and other public health organizations. We also discuss the implications of broader policies, such as policing and public health restrictions, on PWUS and harm reduction.
Substance Use During COVID-19 in Manitoba
In the earliest days of the pandemic, border closures interrupted drug production and distribution across Canada (1). In Manitoba, police crackdowns further disrupted drug supply. This led to decreased availability of certain drugs in the province, and higher prices, particularly for methamphetamines (meth). As a result of higher prices, many PWUS switched their drug of choice, often from methamphetamines to opioids, crack or cocaine. Supply restrictions also increased adulteration (“cutting”) of drugs with fentanyl, as dealers tried to extend their supplies (1). Combined, these factors significantly increased the risk of using substances, leading to a tragic increase in overdose deaths that has been documented in Manitoba throughout the pandemic. Overdose deaths in the province increased by 87% in 2020; in the first six months of 2021, the most recent period for which data are available, they were 44% higher than in 2020 (2). There is evidence that over-policing substance use reduces the availability of safer drugs, discourages safe injection practices, results in Indigenous and Black Canadians being jailed at higher rates than other Canadians, and decreases willingness to carry harm reduction supplies amongst PWUS (3–5). One way to reduce harms for people who use substances is to address the underlying causes of social, economic, and health inequalities in Manitoba, rather than policing substance use.
Safer use of substances
The Manitoba Harm Reduction Network (MHRN) implemented several programs to enhance the safety of substance use during the pandemic. The first was a pilot “locker program”. PWUS were given a personal locker in a public space outside of a primary care clinic. This locker was used as a no-contact distribution system for harm reduction supplies and other personal necessities. The locker program reduced potential COVID-19 exposures and ensured that supplies remained available even when community service organizations were closed. Tailored care packages were also developed for participants based on personalized needs assessments by MHRN staff. These care packages were distributed in the lockers with harm reduction supplies. PWUS found these more beneficial than general care packages: typical contents included gift cards, menstrual (period) supplies, winter gear, food, cleaning supplies, money, safe sex supplies, and personal protective equipment like masks. The lockers were also successfully used to distribute traditional medicines like cedar and sage. This had an added benefit of strengthening MHRN’s partnerships with Indigenous organizations, who could source medicines in a culturally and spiritually appropriate way.
Public health messaging about harm reduction emphasizes that people should not use substances alone. However, public health messaging about COVID-19 encouraged reducing contacts and self-isolating. The evaluation found that PWUS typically continued to use substances communally if they did so before to the pandemic, regardless of provincial messaging and restrictions. Clearer public messaging around how to reduce COVID-19 risks while using substances is needed: PWUS were concerned about contracting COVID-19, but perceived the risk of overdose to be higher. Training PWUS in “virtual spotting”, a remote supervised-consumption model, may be beneficial, as shown by initial reports from a University of Toronto study (6).
Overdose prevention services like outreach vans were less available during the pandemic, so MHRN took advantage of ongoing gatherings of PWUS to reduce overdose risks. MHRN provided PWUS with CPR training, and taught them how to administer naloxone. MHRN staff distributed naloxone kits, fentanyl testing strips, and other harm reduction supplies through the locker program. PWUS were then responsible for distributing these supplies to others in their communities. There were many advantages to this training, and this way of distributing supplies. PWUS found it was good for their mental health to be able to support their community; it increased referrals to MHRN while making it less likely PWUS and MHRN staff would catch COVID-19; and it reduced the workload of MHRN staff.
Availability of services
PWUS were more likely than other Manitobans to be negatively affected by closures and changes in the way medical and social services were offered during the pandemic. Most in-person services were unavailable, less available, or required booking appointments by telephone. A significant increase in houselessness during the pandemic, coupled with low availability of personal phones or internet connected devices, meant that PWUS could not use virtual and tele-services (7,8). The provision of cell phones with minutes to PWUS is a simple solution that would enable appointment booking and participation in tele-appointments. This was suggested by numerous PWUS, and can be done in all but the most remote parts of Canada.
Medical services
Some medical services were less available to PWUS than others. Nurses who normally provide testing and treatment clinics for sexually transmitted and blood-borne infections (STBBI) were often reassigned to work on COVID-19, and clinics were cancelled or unavailable. PWUS were unanimous in agreeing that STBBI services were now difficult to find and use in Manitoba. STBBI testing and treatment has also declined in other provinces/territories, due to the urgent public health needs created by the pandemic (8–10). Harm reduction agencies can try to address gaps in STBBI services by providing harm reduction and safe sex supplies through locker programs, and by making sure that these supplies are available in many community locations to reduce contacts for PWUS. This approach worked well for MHRN. There is still a need for public health to increase the availability of STBBI care, and to make sure that STBBI care is available even during a pandemic. If STBBI services need to be paused for short periods, public health should focus on testing and treating PWUS, who are at higher risk of infection. This can be done most easily by continuing to provide services at community clinics with harm reduction agencies.
The difficulty of seeing healthcare practitioners like doctors had many negative effects for PWUS. Several PWUS lost EIA/B or disability benefits because they were unable to make appointments with practitioners to get the paperwork they needed. Other PWUS were unable to meet with healthcare practitioners to have prescriptions for methadone or suboxone renewed. Many people in this situation relapsed to using higher-risk street drugs as a result. Where possible, community-based healthcare practitioners should continue to offer drop-in office hours for PWUS, and use masks and social distancing to reduce the risk of catching COVID-19. Vancouver’s MySafe program also offers a way for PWUS to receive medications without having to see a healthcare practitioner. MySafe is a pharmaceutical (drug) storage device that distributes prescribed opioid medications using biometric technology (a palm-print scan). This device allows PWUS to get a safe drug supply without having to see a doctor or a pharmacist in person. People who sign up for the program can get opioids at any point in time within the 24-hour daily prescription (11–13).
Almost all PWUS reported that, during the pandemic, they were discriminated against by healthcare practitioners for using substances. Other studies have shown this makes people avoid medical care, which in turn makes their health worse (9,10,14). The pandemic made it harder for PWUS to find doctors who were not discriminatory. There were fewer doctors available due to pandemic restrictions, particularly in hospitals, and those who were supportive of harm reduction were not always available. Hospitals need to develop methods to find out if PWUS are being discriminated against. PWUS are often houseless, so they cannot fill out quality of care surveys that are mailed to them. Hospitals should explore other methods of assessment, including semi-regular conversations with PWUS coordinated by harm reduction agencies. PWUS suggested that advocates (friends or others who can support and guide patients) are very helpful, both to reduce experiences of discrimination and to help them understand their care. It is possible that hospital restrictions limiting visitors have affected patient care for PWUS in particular, by reducing their ability to have medical advocates. Numerous PWUS reported asking emergency medical practitioners how to safely switch substances, and said that this was not information that doctors or nurses knew. This suggests a need for hospitals to train doctors and nurses in harm reduction medicine, going beyond “use clean supplies” to being able to provide information on topics like switching substances safely, tapering medications, and relapsing to street drug use.
Mental health services
The pandemic has been harmful to the mental health of the population, and PWUS are more likely to have had negative changes in their mental health (9,14,15). Every PWUS who participated in the evaluation had been affected by overdose, their own or those of loved ones, during the pandemic. Many were also affected by completed and incomplete suicides. Elders are a very important resource for many PWUS in maintaining mental and spiritual health. Unfortunately, Elders were less available because community events were cancelled, and also because there was a lot of demand for their support. MHRN was able to coordinate some in-person, group activities with Elders when public health restrictions allowed. PWUS suggested that, if Elders thought it was appropriate, online conversation groups would also be helpful. Since most PWUS do not have computers, these groups could be held at harm reduction agencies, with distanced and masked participants.
Most PWUS reported that mental health services (psychiatric, psychological, and counselling) were harder to use because appointments were only available virtually. Those who work in mental healthcare can provide better support if they understand the way that their clients live. This includes understanding their living situation – i.e., that internet-connected devices are not often available to them – and adapting their delivery of care to that reality. It is also necessary for mental health professionals to understand how discrimination, colonization, and social inequalities affect mental health and substance use (16). Actively working towards reconciliation is essential in improving mental health outcomes.
Harm reduction offices are places where PWUS can receive support, particularly when they are grieving someone who died of an overdose. These spaces were less available during the pandemic, and this was hard for both harm reduction staff and PWUS. Many PWUS said that helping others was good for their mental health, and partly made up for the closure of harm reduction offices. Some ways that they helped others included harm reduction supply distribution, cleaning rooms at shelters, and providing childcare. Harm reduction agencies and community organizations should support these efforts. They can do this by providing harm reduction supplies and training sessions on topics like “how to respond to overdose”, and by recognizing and celebrating the work done by PWUS.
Harm reduction workers: well-being during the COVID-19 pandemic
Across Canada, harm reduction workers have also been affected by the pandemic (7). All staff had felt grief and loss during the pandemic. These feelings were harder because they could not see each other in person and comfort each other. Many were worried about getting COVID-19 during work. All MHRN staff agreed that they had to do much more work to support PWUS. Some requested additional training for how to do their work in online or telephone formats. New project funding was available to help PWUS, but this created even more work for staff.
Harm reduction agencies can address these challenges by creating and following COVID-19 safety guidelines for in-person meetings. They should also develop best practices for telephone and virtual meetings. Agencies should offer regular, online conversations about dealing with grief, which are facilitated by someone trained in mental health. Harm reduction funders should consider putting additional money into usual operations, not pilot projects, to support this essential work during a challenging time.
The lives of PWUS
Housing
The pandemic made life harder for PWUS, particularly in the areas of housing and personal finance. Many PWUS became houseless during the pandemic. This was for several reasons: shelters and emergency housing were closed, there was less available low income housing, and support services that help people find housing were closed. Some PWUS were evicted because landlords were concerned that substance use would facilitate the spread of COVID-19. Many social services require a fixed address, so it became harder for PWUS to get other supports as a result. PWUS who did not have a fixed address moved between houses and saw more people. This increased the risk that they would get COVID-19. Emergency housing should be available during a pandemic. There is an immediate need for more emergency housing in Manitoba. There is also a need to spend money over a longer period to develop new housing. Government departments that are in charge of housing should think about pandemics when they plan for the future.
Money
Most PWUS had less money during the pandemic. This was because: they lost jobs and chances to get jobs; they lost EIA/B or disability benefits; food banks and clothing donation sites closed; and because they had to pay for items like masks. PWUS who received the Canada Emergency Response Benefit (CERB) said it let them find safe housing and meet their basic needs, and that this improved their mental health. Research shows that government programs that guarantee people have enough money to live on (universal basic income) can be good for the health of PWUS (17). Other research has shown that these programs can increase use of substances and overdose deaths (17). That said, in Manitoba, increasing drug costs led to higher-risk substance use, so it is possible more money would lead to safer choices of substances. In addition, an American Indian (sic) group of teenagers whose families received enough money to live on were less likely to have substance use disorders (a medical condition in which a person is not able to control their use of substances) (17). CERB, and programs like it, could potentially make the lives of PWUS better. However, many PWUS did not know if they could sign up for the program. Those who received it were worried that they would have to repay it, and maybe lose other benefits. Others lost EIA/B or disability payments because they could not meet doctors to get the paperwork they needed. Community service agencies can help by working with PWUS to help them decide if they are eligible for CERB and other programs. Food banks and clothing donation sites should think about whether they can provide this support in a no-contact way.
Discussion
For people who use substances in Manitoba, the pandemic has led to: poor mental health, increased houselessness, decreased financial stability, higher-risk substance use, and lower availability of harm reduction services, particularly STBBI testing. Discrimination and the effects of colonization shape health outcomes for PWUS (18,19), and the impact of these structural issues has increased during the pandemic. The pandemic has also increased the vulnerability of PWUS to overdose and sexually transmitted and blood-borne infections (20,21). Public health and harm reduction agencies can improve outcomes for PWUS during the pandemic by: providing cell phones; using contactless lockers for distribution of supplies, care packages, and prescription medications; implementing peer-based overdose prevention programs, including virtual spotting; and providing STBBI testing clinics.
Many PWUS are disadvantaged in multiple ways in society: these disadvantages are often referred to as structural causes of their health outcomes (14,21,22). To address the structural causes of the health inequalities experienced by PWUS, changes are required in medical, social, and legal systems. These changes vary in scope, and in their “nearness” to public health. They include: development of policies that recognize the role housing plays in health; investment in emergency housing; elimination of medical discrimination on the basis of substance use; training medical practitioners to provide information about safer substance use; investment in STBBI healthcare so that continued care is available during pandemics; recognizing reconciliation as essential to mental health; and cessation of enforcement-based approaches to drug use. These changes have the potential to significantly improve health for PWUS.
References
Available in pdf document.