Multi-level influences on increased overdose risk behaviors during the COVID-19 pandemic among people who use drugs in Rhode Island: a qualitative investigation

Abstract

Background The ongoing COVID-19 pandemic has disproportionately affected structurally vulnerable populations including people who use drugs (PWUD). Increased overdose risk behaviors among PWUD during the pandemic have been documented, with research underscoring the role of influencing factors such as isolation and job loss in these behaviors. Here, we use qualitative methods to examine the impact of the COVID-19 pandemic and pandemic-related response measures on drug use behaviors in a sample of PWUD in Rhode Island. Using a social-ecological framework, we highlight the nested, interactive levels of the pandemic’s influence on increased overdose risk behaviors. Methods From July to October 2021, semi-structured interviews were conducted with 18 PWUD who self-reported any increase in behaviors associated with overdose risk (e.g., increased use, change in drug type and/or more solitary drug use) relative to before the pandemic. Thematic analysis was conducted using a codebook with salient themes identified from interview guides and those that emerged through close reading of transcribed interviews. Guided by a social-ecological framework, themes were grouped into individual, network, institutional, and policy-level influences of the pandemic on drug use behaviors. Results Individual-level influences on increased overdose risk behaviors included self-reported anxiety and depression, isolation and loneliness, and boredom. Network-level influences included changes in local drug supply and changes in social network composition specific to housing. At the institutional level, drug use patterns were influenced by reduced access to harm reduction or treatment services. At the policy level, increased overdose risk behaviors were related to financial changes, job loss, and business closures. All participants identified factors influencing overdose risk behaviors that corresponded to several nested social-ecological levels. Conclusions Participants identified multi-level influences of the COVID-19 pandemic and pandemic-related response measures on their drug use behavior patterns and overdose risk. These findings suggest that effective harm reduction during large-scale crises, such as the COVID-19 pandemic, must address several levels of influence concurrently.

The impact of the COVID-19 pandemic on people who use drugs in three Canadian cities: a cross-sectional analysis

“…Equally important, participants across settings also reported decreases in income and greater food insecurity, with individuals in Vancouver experiencing better outcomes in these indicators compared to participants in Toronto and Montreal. These findings are corroborated by other investigations among people who use drugs which found that pandemic-related restrictions negatively impacted income generation and ability to meet material needs, primarily due to job loss and decreased ability to engage in informal street-based income generation activities (i.e., panhandling) [ 15 , 24 ]. We also found that across sites, among participants who experienced a change in living situation, slightly less than half reported improvements while over a third reported that their living circumstances worsened.…”

“…Although findings should be considered in light of baseline measures of housing instability in these settings prior to the pandemic, they nonetheless indicate high—and increasing—unmet housing needs in this population during this time. While housing instability is common among people who use drugs and may in part explain reported changes in housing circumstances among participants [ 43 ], many Canadian cities implemented temporary shelters and hotel programs to accommodate people experiencing homelessness in the initial phase of COVID-19 restrictions so that they could comply with public health distancing ordinances [ 15 , 16 ]. These temporary housing programs were not uniformly implemented across cities, and permanent housing shelters either closed or underwent critical operational changes, negatively impacting equity-seeking groups, including people who use drugs [ 16 ].…”

“…These temporary housing programs were not uniformly implemented across cities, and permanent housing shelters either closed or underwent critical operational changes, negatively impacting equity-seeking groups, including people who use drugs [ 16 ]. Given moderately high levels of homelessness experienced by participants in Montreal and Toronto during the pandemic, preparedness measures must prioritize equitable access to stable, safe, and affordable housing in advance of public health emergencies or other large-scale disruptive events [ 15 ]. Interventions to consider include rent or mortgage deferrals, anti-eviction policies, and sustainable options for temporary and transitional housing [ 15 ].…”

“…Given moderately high levels of homelessness experienced by participants in Montreal and Toronto during the pandemic, preparedness measures must prioritize equitable access to stable, safe, and affordable housing in advance of public health emergencies or other large-scale disruptive events [ 15 ]. Interventions to consider include rent or mortgage deferrals, anti-eviction policies, and sustainable options for temporary and transitional housing [ 15 ].…”

Changes to opioid overdose deaths and community naloxone access among Black, Hispanic and White people from 2016 to 2021 with the onset of the COVID‐19 pandemic: An interrupted time‐series analysis in Massachusetts, USA

“…Further research is needed to understand whether the surge in the rate of OODs among Black people was due to increased presence of fentanyl in specific drug supplies (e.g. cocaine) and patterns of polysubstance use [11,33], interruptions to other health-care services such as emergency medical services and medications for OUD [34], increasing solitary drug use due to isolation requirements [35,36] or a combination of these factors. It is also imperative to assess whether structural factors and pre-existing challenges that have been exacerbated during the pandemic, such as unstable housing, mental health issues, poverty, poor access to health-care, social isolation and stigmatization [37], are affecting Black people who use drugs disproportionally in the COVID-19 era.…”