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

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.

Revising our attitudes towards agonist medications and their diversion in a time of pandemic.

The COVID-19 pandemic led government regulators to relax prescribing rules for buprenorphine and methadone, the agonist medications that effectively treat opioid use disorder, allowing for take home supplies of up to 28 days. These changes prioritized the availability of these medications over concerns about their misuse and diversion, and they provided a means for overdose prophylaxis during the highly uncertain conditions of the pandemic. In considering how to capitalize on this shift, research should determine the extent to which increased diversion has occurred as a result, and what the consequences may have been. The shifts also set the stage to consider if methadone can be safely prescribed in primary care settings, and if the monthly injectable formulation of buprenorphine is a suitable alternative to increased supplies of sublingual strips if concerns about diversion persist. The disruptions of the pandemic have caused a surge in overdose deaths, so carefully considering the prophylactic potential of agonist medications, in addition to their role as a treatment, may help us address this mortality crisis.

COVID-19 as a Frying Pan: The Promise and Perils of Pandemic-driven Reform.

: The imposition of new regulations can send industries scrambling to comply, fostering innovation in doing so. How we police and treat people with opioid use disorder (OUD), with recent widespread social unrest in reaction to police violence and systemic racism bringing the need for lasting structural changes to our justice system and social services into especially acute relief. Arbitrary laws and counterproductive policies previously subject to only incremental reform have given way to sweeping changes: people convicted of nonviolent drug crimes have been released from jails and prisons, the enforcement of drug laws has been cast aside as a priority, and the regulations surrounding addiction treatment medications and treating patients with OUD have been greatly loosened. These are changes many practitioners and advocates have sought for years if not decades, but they come with the reality that the old systems are culturally entrenched and likely to be resilient. It is critical that researchers evaluate these changes and synthesize the results with existing evidence in ways that empower efforts to make the most effective responses permanent. The COVID-19 pandemic makes for a challenging research environment, but its OUD-related interventions have created new regulatory systems that lend themselves to valuable opportunities for evaluation as natural experiments by the burgeoning field of legal epidemiology.