Those struggling with addiction face double risk during COVID-19 pandemic, advocates say

“It’s a lot harder to get people the services they need. And that is absolutely going to have a negative impact on overdose rates.”

A man holds up a dose of Narcan in Boston. –Jessica Rinaldi / Boston Globe

Even as the COVID-19 pandemic ravages lives around the world, the opioid epidemic continues to rage in New England and claim its own victims.

Most business may have halted in the path of the novel coronavirus, but Sarah Mackin, director of harm reduction services for Boston’s AHOPE, cautioned that the overdose crisis continues on a daily basis and those struggling still need resources on their paths to recovery from addiction. 

She and her colleagues within the Boston Public Health Commission are working to continue to provide support to those struggling with substance use disorder, adjusting programming operations to meet social distancing guidelines and measures to prevent the spread of COVID-19.

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“We are seeing HIV outbreaks, both in the city and across the state, which is really concerning from the point of view of a public health person and a harm reduction person,” she told Boston.com. “It’s something that we haven’t seen in decades, and it’s really really concerning. So we know that we have to continue to provide really critical services to people because we don’t want people to die of overdoses and we don’t want them to get HIV.”

Like many other services, AHOPE has altered its congregate programming, closing its drop-in center and moving support services outdoors at 774 Albany St. There, underneath a tent, AHOPE has set up a table with supply kits for people in need, which they are handing out.  

AHOPE is also still running its needle exchange program, and the city’s mobile outreach, a van that functions as a licensed public health clinic that provides critical medical services and Suboxone across the city, is still going out three days a week. 

But, like most services, it has been adjusted out of concern for the coronavirus. Instead of allowing three or four people in the van at a time, one person is allowed in at a time with the health care provider. 

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“We can’t afford to stop doing syringe access and doing harm reduction,” Mackin said. “Because [otherwise] at the end of all this, we’re going to have a huge influx of new HIV cases. So we’re just trying to make sure that no matter what comes down the pike, that we are out there on the ground on the front lines to make sure people get what they need. Because if we don’t, then there’s going to be a lot of unnecessary suffering.”

Mackin said she and her colleagues are trying to get as many people on medication-assisted treatment, or MAT, as possible.

AHOPE has moved to a telehealth model for helping people get treatment, working with Boston Medical Center and Project Trust to fill in the gap of walk-in services. PAATHS (Providing Access to Addictions Treatment, Hope and Support) is also still placing people into detox programs, Mackin said.

The Substance Abuse and Mental Health Services Administration has also relaxed some restrictions for MAT, allowing some patients to take home two weeks worth of treatment in response to the coronavirus outbreak rather than require them to visit clinics daily for their doses. 

Mackin praised the move, but said each regulatory change or alteration in services brings about its own set of logistical challenges. For example, methadone clinics require that patients store the additional medication in a lock box in order to bring it outside the clinic. But clinics aren’t giving out the lock boxes, and Mackin said she’s had people come to AHOPE asking if any are available. 

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“We can make these regulatory changes but we have to understand how it impacts people on the individual level, and we have to provide them with everything that they need so that these changes, which are intended to keep people on medication for addiction treatment, is actually doing what it’s intended to do,” Mackin said. “That includes making sure that people have a secure place to put [the medication] when they’re in their shelters or when they’re in the COVID tent. Or anywhere they’re staying that they have a lockbox if they’re even eligible to have a take-home.”

Given the overlap between homelessness and substance use disorder, Mackin said treatment services are being “layered in” at the tents set up by Boston’s Healthcare for the Homeless to make sure anyone can get onto medication if they need it, or be prepared for going through detox at the tent if needed. But the tents are also prepared to house people who may be in active use.

The changes to services may seem “minute,” Mackin said, but for the population she and her colleagues are serving, they are “impactful.”

“Not having a space to come in and relax, and hang out and hang with the AHOPE staff and talk to them, and have a chance to engage in a leisurely way and maybe pull them aside for conversation or pull them into a room to do HIV testing — those things have an impact on people,” she said.

And even with the efforts being made to maintain the same level of support and service to those who are active users, the director of harm reduction services said she is concerned that people will see disruptions in access to treatment.

“We’re addressing one crisis at the expense of another,” she said.

Getting in for treatment when you need it becomes a lot harder when you can’t just walk into a clinic to see a provider, she said. Screening procedures checking for symptoms of the virus (cough, shortness of breath, fever) could get people screened out of inpatient detoxes. But, Mackin pointed out, a fever can also be a symptom of withdrawal, and people who struggle with substance use or who are homeless are typically always getting colds.  

“It’s a lot harder to get people the services they need,” Mackin said. “And that is absolutely going to have a negative impact on overdose rates. There’s no way around it.”

Mackin said the feelings of isolation everyone is experiencing because of the coronavirus epidemic are of particular concern for people in recovery, who rely on the community support of NA or AA. 

In-person meetings have been halted and many meetings have moved online, a resource Boston Mayor Marty Walsh says he is himself taking advantage of. 

“Alcoholism and drug addiction is a disease of isolation,” Walsh told the Boston Globe. “For someone with longtime sobriety, their whole way of dealing with addiction is interacting with people. Not having access to the program and the meetings is really difficult on people.”

Mackin said she’s concerned about a rise of people experiencing depression and substance use as a result of the coronavirus outbreak, particularly among those who are already struggling.

“Homeless folks are lonely,” she said. “All of their bridges are burnt. Their connections, their social connections are a lot of times the service providers and each other. And to not be able to get any comfort when you’re dealing with chaotic substance use and you’re dealing with mental illness and you’re dealing with medical conditions and you’re scared — to not be able to give a hug to someone or feel physically comforted, that’s horrible. And that’s going to reverberate through the entire community, and homeless folks are not an exception.”

People struggling with substance use often have co-occurring medical issues, such as Hepatitis C or respiratory conditions like COPD, which put them at higher risk for severe complications from COVID-19. If people struggling with substance use are also living in a communal setting, that also places them at higher risk of contracting the virus.

“I think our people are going to bear a disproportionate amount of the burden for this,” Mackin said. “Our people are already sick, they don’t have the option to self-isolate. We’re just going to do the best that we can for people. I just think it’s really important for service providers to understand that the world doesn’t stop because of a pandemic. And we have to make sure that we are out there as much as we possibly can and getting people what we need.”

Measures are being taken to try to prepare and slow the spread of the virus as much as possible in the population, she said. 

“I think we’re doing the best we can, but it is an eventuality that our people are going to be severely impacted by this and it’s what we do now that determines the outcome,” she said. “We do as much as we can on the front end, so we can flatten that curve so that when we have a bunch of homeless folks that are really really super sick, they can get the medical care that they need.” 

Mackin said on the ground, participants in AHOPE are expressing a range of emotions in response to the pandemic, from fear to going about their daily business of survival. 

More and more, she said, they are getting the message that they can’t be somewhere. 

“It’s just that heartfelt plea, that ‘I just want to be able sit down someplace warm and calm and be able to feel safe,’ and there’s not many of those places right now, which is really hard,” the harm reduction director said. “It’s having a really negative impact on people’s mental health and emotional health.”

The adjustments made in recent weeks to help stem the spread of COVID-19 have been painful for Mackin too. She’s been working in the field for 10 years and has known some of the AHOPE participants a long time. 

She’s used to hugging them, putting an arm around their shoulders, sitting with them when they come in for support.

“Because nobody else touches our people,” she said. “The way that harm reductionists are, the most important thing that we do is show love to people and we can’t even do that in this epidemic and it’s horrible. It just sucks. So we’re just doing the best that we can to just give out coffee supplies and give out warm food when we have it out front. It’s just really hard to not be able to show our people love when they’re the most scared.”


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