Substance Use Disorder Treatment in the Age of COVID-19: Challenges, Responses, and Lessons for the Future

Measures to control the spread of COVID-19 infections, such as restrictions on movement, social distancing regulations, lockdowns, and curfews, are being applied intermittently around the globe. The application of these control measures has had far-reaching effects on the health of patients with Substance Use Disorder and how services and treatment are being provided to them. In the first part of this chapter, we focus on the health and contextual effects of COVID-19 on people with Substance Use Disorder. We then present current evidence of the effects of COVID-19 on Substance Use Disorder treatment services and providers. Studies from around the globe suggest that COVID-19 has increased the vulnerability and stigma toward people who use drugs and substantially decreased their ability to access needed treatment. The second part of this chapter discusses future models for service provision and their possible benefit to Substance Use Disorder patients, emphasizing the use of telemedicine, e-prescribing, dosing flexibility, take-home medicine, and reach-out initiatives. We suggest that models of care based on remote patient management might benefit some patients, but their universal adoption with insufficient evidence could be detrimental to others needing closer clinical supervision. Using hybrid models, incorporating both person-to-person and remote treatment delivery, changing reimbursement schemes, and using new technologies may increase the benefits of remote patient care. © Springer Nature Switzerland AG 2022.

The increase in benzodiazepine-laced drugs and related risks in Canada: The urgent need for effective and sustainable solutions.

The overdose crisis in Canada has continuously evolved and is increasingly challenging to contain, while efforts from governments and policymakers to address it have often fallen short and resulted in unintended consequences. One of the main repercussions has been an unprecedented rise in adulterants in the illegal drug supply, including a wide array of pharmacological and psychoactive compounds and chemicals, which has resulted in a progressively toxic drug supply. Most recently, there has been a stark increase in synthetic benzodiazepine-laced opioids (i.e., 'benzodope') in some Canadian jurisdictions. This unique combination carries distinct and amplified risks for people who use drugs including fatal and non-fatal overdoses, increased dependence and withdrawal symptoms, and places them in extremely vulnerable positions. The emergence of benzodiazepines within the illicit drug supply has substantially contributed to drug-related morbidity and mortality in Canada, and has further complicated current public health initiatives and overdose prevention efforts. This reality underscores the need for effective and sustainable policy solutions to address the evolving overdose epidemic including increased knowledge and education on the specific harms of opioid and benzodiazepine co-use (especially in regards to the complexity of opioid/benzodiazepine overdoses), scaling-up harm reduction measures, and eliminating the toxic drug supply altogether.

COVID-19, drug use and harm reduction: A comparative perspective from stakeholders in France and Quebec

People who use psychoactive substances and who attend drug treatment and harm reduction services represent groups whose vulnerabilities are exacerbated during a pandemic. We study the pandemic experience of people with problematic substance use and its impact on professional practices and policies, with an eye towards vulnerability and innovations. This comparative study was conducted in France and Quebec via semi-structured interviews with substance users (France, n=25;Quebec, n=15) and care and harm reduction providers (France, n=25;Quebec, n=18). We employ a pragmatist theoretical approach that reflexively analyzes the macro and micro levels together. During the first lockdown, professionals tried their best to organize a continuity of service to meet the needs of people in a context of a health emergency via the deployment of access to accommodation and the development of teleconsultation to ensure continuity of care. Innovative collaborations between actors occurred related to accommodation or the inclusion of harm reduction (alcohol and safe supply) in shelters. Difficulties were observed stemming from organizational constraints. Individuals adopted the preventive measures and had to endure social control both in the health and repressive fields. Beyond the vulnerabilities produced by COVID-19, adaptations also constitute opportunities for: solidarity between users and professionals, professional innovations, as well as new modes of collaboration and inter-actor organization. © 2022 Criminologie. All rights reserved.

Impact of changes to the delivery of opioid agonist treatment, introduced during the COVID-19 pandemic, on treatment access and dropout in Ireland: An interrupted time series analysis.

BACKGROUND: Following the emergence of COVID-19, Ireland introduced national contingency guidelines to ensure rapid and uninterrupted access to opioid agonist treatment (OAT). This study aims to assess the impact of changes introduced to the delivery of OAT on the number of people accessing treatment and treatment dropout. METHODS: The study conducted interrupted time series analyses, with separate segmented regression models (March 2019-February 2020) vs (April 2020-March 2021), for (A) total number of people accessing OAT, (B) the number initiating treatment, and (C) the number dropping out of treatment, using data from the National OAT treatment register. The study examined immediate (change in level or intercept: ß2) and long-term impacts (change in slope; i.e., the difference between the slope before and after the intervention: ß3). We performed total and stratified analyses by gender, age group (<40/≥40 years), and OAT drug (methadone or buprenorphine). RESULTS: A total of 10,251 people accessed OAT in Ireland in March 2019 (2 % buprenorphine, n = 178), increasing to 11,441 (4 % buprenorphine, n = 471) in March 2021. The study observed an immediate (ß2 = 504.3, p < 0.001) and continued (ß3 = 31.9, p < 0.001) increase of people accessing treatment following the introduction of the OAT contingency guidelines. In contrast, observed changes in level and slope were not significant for treatment initiation or dropout. The study did find, however, a modest reduction in dropout among those receiving buprenorphine (ß3 = -0.6, p = 0.036). CONCLUSIONS: Changes introduced to the delivery of OAT, under the COVID-19 contingency guidelines, are associated with increased access to OAT in Ireland, with no evidence of increase in treatment dropout. Whether these effects will be maintained over time remains to be seen.

"It's professional but it's personal": Participation, personal connection, and sustained disagreement in drug policy reform.

While there is widespread agreement as to the importance of increasing participation in drug policy design, drug policy literature contains limited reflection on the practices that may support inclusion and collaboration amongst policy actors, particularly when disagreement and difference are an intrinsic part of participation. Drawing on qualitative interviews and ethnographic fieldwork with actors engaged in an Australian illicit drug policy reform campaign, this paper examines how particular modes of personal connection mattered in establishing and maintaining working relationships between a range of differently situated actors. Through engagement with this case study, we argue that modes of personal connection marked by qualities such as being frank; engaged; not forcing consensus; enacting respect; listening in order to understand; and acting in ways that respected the obligations and limits that came with people's roles while also recognising one another as more than those roles, were particularly important qualities that supported connection across difference. Such personal connections seem to have been even more important for the engagement of people representing more marginal positionalities. Arguing that personal connection is already an element of both inclusion and exclusion in drug policy creation, we suggest that policy actors interested in contributing to a more diverse and rigorous policy participation space attend to how people connect, with whom, and with what space for disagreement, while also taking seriously the labour of such connection across difference.

Mifepristone (RU-486®) as a Schedule IV Controlled Drug-Implications for a Misleading Drug Policy on Women's Health Care.

BACKGROUND: Mifepristone (RU-486) has been approved for abortion in Taiwan since 2000. Mifepristone was the first non-addictive medicine to be classified as a schedule IV controlled drug. As a case of the "misuse" of "misuse of drugs laws," the policy and consequences of mifepristone-assisted abortion for pregnant women could be compared with those of illicit drug use for drug addicts. METHODS: The rule-making process of mifepristone regulation was analyzed from various aspects of legitimacy, social stigma, women's human rights, and access to health care. RESULTS AND DISCUSSION: The restriction policy on mifepristone regulation in Taiwan has raised concerns over the legitimacy of listing a non-addictive substance as a controlled drug, which may produce stigma and negatively affect women's reproductive and privacy rights. Such a restriction policy and social stigma may lead to the unwillingness of pregnant women to utilize safe abortion services. Under the threat of the COVID-19 pandemic, the US FDA's action on mifepristone prescription and dispensing reminds us it is time to consider a change of policy. CONCLUSIONS: Listing mifepristone as a controlled drug could impede the acceptability and accessibility of safe mifepristone use and violates women's right to health care.

Substance use policy and practice in the COVID-19 pandemic: Learning from early pandemic responses through internationally comparative field data.

The COVID-19 pandemic has created an unprecedented natural experiment in drug policy, treatment delivery, and harm reduction strategies by exposing wide variation in public health infrastructures and social safety nets around the world. Using qualitative data including ethnographic methods, questionnaires, and semi-structured interviews with people who use drugs (PWUD) and Delphi-method with experts from field sites spanning 13 different countries, this paper compares national responses to substance use during the first wave of the COVID-19 pandemic. Field data was collected by the Substance Use x COVID-19 (SU x COVID) Data Collaborative, an international network of social scientists, public health scientists, and community health practitioners convened to identify and contextualise health service delivery models and social protections that influence the health and wellbeing of PWUD during COVID-19. Findings suggest that countries with stronger social welfare systems pre-COVID introduced durable interventions targeting structural drivers of health. Countries with fragmented social service infrastructures implemented temporary initiatives for PWUD led by non-governmental organisations. The paper summarises the most successful early pandemic responses seen across countries and ends by calling for greater systemic investments in social protections for PWUD, diversion away from criminal-legal systems toward health interventions, and integrated harm reduction, treatment and recovery supports for PWUD.

Transnational organized crime and COVID: A book review essay

COVID-19, Gangs, and Conflict. Edited by John P. Sullivan and Robert J. Bunker. A Small Wars Journal-El Centro Reader. Bloomington: Xlibris. 2020. Photos. Endnotes. Contributor biographies. Prologue. Foreword. Postscript. Afterword. Selected References. pp. 153. Paperback $12.17. Kindle $3.99. Criminal Contagion: How Mafias, Gangsters and Scammers Profit from a Pandemic. By Tuesday Reitano and Mark Shaw. London: Hurst and Company, 2021. ISBN 9781787384460. Notes. Index. pp. 320. Hardcover $26.95.

"They're causing more harm than good": a qualitative study exploring racism in harm reduction through the experiences of racialized people who use drugs.

BACKGROUND: Increased opioid-related morbidity and mortality in racialized communities has highlighted the intersectional nature of the drug policy crisis. Given the racist evolution of the war on drugs and the harm reduction (HR) movement, the aim of this study is to explore racism within harm reduction services through the perspectives of our participants. METHODS: We conducted a qualitative descriptive study to explore the perspectives of racialized service users and providers on racism in the HR movement in the Greater Toronto and Hamilton Area (GTHA). Four racialized service users and four racialized service providers participated in semi-structured interviews that were audio-recorded, transcribed, and analysed thematically. RESULTS: Five themes related to racism in HR were generated: (1) whiteness of harm reduction as a barrier to accessing services, (2) diversifying HR workers as a step towards overcoming distrust, (3) drop-in spaces specific to Black, Indigenous, and people of colour are facilitators to accessing harm reduction, (4) lack of representation in HR-related promotional and educational campaigns, and (5) HR as a frontier for policing. CONCLUSIONS: Our findings suggest that structural and institutional racism are prevalent in HR services within the GTHA, in the form of colour-blind policies and practices that fail to address the intersectional nature of the drug policy crisis. There is a need for local HR organizations to critically reflect and act on their practices and policies, working with communities to become more equitable, inclusive, and accessible spaces for all people who use drugs.

Established Tables and Emergent Huddles: Exploring the Processes of Participation Associated With the Policy Changes to Opioid Pharmacotherapy Treatment in Australia in the Context of COVID-19

In this paper we document and analyze emergent participatory processes in drug policy, focusing on the relations between established modes of engagement and emergent participatory formats. We do this through analysis of a case example, attending to policy changes to opioid pharmacotherapy treatment in the context of COVID-19 in Australia. Semistructured interviews (n = 22) were undertaken between August 2020 and March 2021 with people closely involved in the recent policy changes and discussions surrounding opioid pharmacotherapy treatment in Australia. The analysis of the interview accounts followed work which has forged relational, co-productionist and materialist understandings of participation. Two figures of participation were encountered in the interview accounts: the tables of participation and the huddles of participation. The tables seemingly represented a standardized set of bureaucratic mechanisms for the inclusion of the “voices” of people who use drugs. The huddles emerged as a responsive and less coherent set of ad hoc participatory collectives in the context of rapid policy changes during COVID-19. Instead of viewing emergence as distinct from existing participatory formats, emergence was conceptualized ecologically in this article—that is in relation to established forms of participation. As the institutionally mandated tables served the basis for the emergent huddles of participation in this case study, it demonstrates that even the most foreclosed participatory structures can adapt and be responsive to evolving situations of need, perhaps also in ordinary times and not just in emergency conditions. [ FROM AUTHOR] Copyright of Contemporary Drug Problems is the property of Sage Publications Inc. and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use. This may be abridged. No warranty is given about the accuracy of the copy. Users should refer to the original published version of the material for the full . (Copyright applies to all s.)

Racial resentment and support for decriminalization of drug possession in the United States.

Drug criminalization creates significant barriers to prevention and treatment of substance use disorders and racial equity objectives, and removal of criminal penalties for drug possession is increasingly being endorsed by health and justice advocates. We present empirical data estimating the share of U.S. adults who support eliminating criminal penalties for possession of all illicit drugs, and examine factors associated with public support. Data from the Johns Hopkins COVID-19 Civic Life and Public Health Survey, a probability-based nationally representative sample of 1222 U.S. adults, was collected from November 11-30, 2020. Support for decriminalizing drug possession was assessed overall and by sociodemographic factors and attitudes towards politics and race. Correlates of support were examined using multivariable logistic regression. Thirty-five percent of adults supported eliminating criminal penalties for drug possession in the U.S. In adjusted regression models, respondents who were younger or identified as politically liberal were more likely to support decriminalization relative to other groups, and respondents who were Hispanic or identified strongly with their religious beliefs were less likely to support decriminalization. Among white respondents, greater racial resentment was strongly associated with reduced support for drug decriminalization. Support for drug decriminalization varies considerably by beliefs about politics and race, with racial resentment among white Americans potentially comprising a barrier to drug policy reform. Findings can inform communication and advocacy efforts to promote drug policy reform in the United States.

Consensus recommendations for opioid agonist treatment following the introduction of emergency clinical guidelines in Ireland during the COVID-19 pandemic: A national Delphi study.

BACKGROUND: Emergency contingency guidelines for opioid agonist treatment (OAT) were introduced in Ireland in March 2020, to ensure rapid and uninterrupted access to treatment while mitigating COVID-19 risk. The contingency guidelines deviated, across multiple clinical domains, from pre-pandemic clinical guidelines published in 2016. The objectives of this study are to (1) identify changes introduced to OAT clinical guidelines in Ireland during the pandemic; and (2) develop consensus on whether the new recommendations should be retained beyond the pandemic, using a national Delphi consensus methodology. METHODS: Clinical guidance recommendations ('statements') were generated by comparing the newly established contingency guidelines with the national 2016 Clinical Guidelines for OAT. Over two rounds of on-line Delphi testing, a panel of experts (people currently accessing OAT, psychiatrists, general practitioners, community pharmacists, a nurse, a psychologist and support/key workers) independently rated their agreement with each statement and provided comments. Statements with a median score of 4 or 5 and a lower quartile of ≥4 were classified as having reached consensus. RESULTS: Forty-eight panel members were recruited, with a high participation level at Round 2 (90%, n=43). Consensus was achieved for 12 of the 19 statements at Round 1. The 7 remaining statements were revised, with 2 new statements, resulting in 9 statements at Round 2. Four statements reached consensus at Round 2. The final list includes 16 clinical guidance statements; 9 relating to assessment, 3 to OAT drug choice and dosing, 1 to take-away doses, 2 to overdose prevention and 1 to the continuation of e-prescriptions. CONCLUSIONS: A wide range of stakeholders involved in the delivery and receipt of OAT agreed on 16 clinical guidance statements for inclusion in OAT clinical guidelines as we move beyond the pandemic, rather than reverting to pre-pandemic guidelines. The agreed statements relate to facilitating safe access to OAT with minimal waiting time, supporting patient-centred care to promote health and well-being, and preventing drug overdose. Notably, consensus was not achieved for OAT drug dosage and frequency of urine testing during the stabilisation and maintenance phase of care.

Ayahuasca and Public Health II: Health Status in a Large Sample of Ayahuasca-Ceremony Participants in the Netherlands.

Ayahuasca is a plant decoction in traditional Amazonian medicine. Its ritual use has been internationalized, leading to policy challenges that countries should address. This study evaluates the impact of regular ayahuasca ceremony participation on health by assessing the health status of 377 participants in ayahuasca ceremonies in the Netherlands using validated health indicators. A questionnaire was developed and administered to study participants. The questionnaire included several health indicators with public health relevance (e.g., BMI, diet, physical activity) and psychometrically validated questionnaires (ELS and COPE-easy). The data retrieved through health indicators was compared to normative Dutch data. Participants (50.1% women) were mostly Dutch (84.6%) with a mean age of 48.8 years (SD = 11.6). Compared to normative Dutch data, regular participants in ayahuasca ceremonies showed better general well-being, fewer chronic or lifestyle-related diseases, more physical activity, and a more balanced diet. Participants also used less alcohol during the COVID-19 pandemic, and although they used more illegal drugs than the general population, they did not report associated harms. Our findings suggest that regular participation in ayahuasca ceremonies is not linked to relevant health harms. This data could help drug policymakers to develop and implement evidence-based public policies.

International trends in prescription opioid sales among developed and developing economies, and the impact of the COVID-19 pandemic: A cross-sectional analysis of 66 countries.

PURPOSE: We sought to compare trends in opioid purchasing between developed and developing economies to understand patterns of opioid consumption, and how they were impacted by the COVID-19 pandemic. METHODS: We conducted a retrospective cross-sectional study of retail pharmacy opioid sales from 66 jurisdictions between July 2014 and August 2020. We measured monthly population-adjusted rate of opioid units purchased, stratified by development group and country, and used interventional time series analysis to assess the impact of the COVID-19 pandemic on rates of opioid purchasing among developed and developing economies separately. RESULTS: Rates of opioid purchasing were generally higher among developed economies, although trends differed considerably by development group. Rates of opioid purchasing declined 23.8% (95% confidence interval [CI] -34.7% to 3.6%) in the 5 years prior to the pandemic in developed economies, but rose 15.2% (95% CI 4.6%-35.6%) among developing economies. In March 2020 there was a short-term increase in the rate of opioid purchases in both developing (10.9 units/1000 population increase; p < 0.0001) and developed (145.5 units/1000 population; p < 0.0001) economies, which was followed immediately by reduced opioid purchasing of a similar scale in April-May 2020 (-14.8 and -171.8 units/1000 population in developing and developed economies, respectively; p < 0.0001). CONCLUSION: The COVID-19 pandemic led to disruptions in opioid purchasing around the world; although the specific impacts varied both between and among developed and developing economies. With global variation in opioid use, there is a need to monitor these trajectories to ensure the safety of opioid use, and adequate access to pain management globally.

Different Paths and Potentials to Harm Reduction in Different Welfare States: Drug Consumption Rooms in the United Kingdom, Denmark, and France

The harm reduction approach entered British national policy after the Thatcher government-which was no friend of the welfare state-accepted the 1988 recommendation of the Advisory Council on the Misuse of Drugs, which asserted that preventing HIV transmission was more important than insisting that people stop using heroin.16 Rates of HIV and hepatitis C among people who inject drugs are still much lower in the United Kingdom than in the United States. Since the 1990s, support for harm reduction in UK policy and funding has waxed and waned. Cuts to treatment budgets, recommissioning of treatment services, and a push for people to leave treatment drug-free were followed byannual increases in drug-related deaths starting in 2013 and a decrease in the number of people in treatment.20 The most recent UK government drug strategy (published in December 2021) makes little direct mention of harm reduction but does include it in the wide range of services in which GBP780 million of new funding is to be invested from 2022 to 2025 in England.21 The UK government is also reviving punitive rhetoric alongside its new investment in treatment services, blaming drug users rather than blanket prohibition for the harms of organized crime and ruling out DCRs on spurious legal grounds.22 It was left to an activist with a lived experience of problematic drug use to set up the first overdose prevention service in the United Kingdom, which they did in a secondhand vehicle on the streets of Glasgow in 2020-2021. Graduated goals meant that treatment "should not only aim to 'heal' addiction, but to provide rehabilitating measures while drug abuse continues"28(p132) and should include basic improvement of physical health and improvement of the situation of those who use drugs, including through abstinence. Danish drug policy as It was developed during the 1960s and 1970s was based on the Ideas that criminal sanctions should reduce the supply of drugs and that social welfare measures should reduce the demand for drugs.29 This meant that possession of Illicit drugs for personal use was depenalized from 1969 to 2004.

COVID-19 economic impact payments and opioid overdose deaths.

BACKGROUND: Given the global economic recessions mediated by the COVID-19 pandemic and that many countries have implemented direct income support programs, we investigated the timing of the COVID-19 economic impact payments and opioid overdose deaths. METHODS: A longitudinal, observational study design that included data from the Ohio Department of Health was utilized. Statistical change point analyses were conducted to identify significant changes in weekly number of opioid overdose deaths from January 1 of 2018 to August 1 of 2020. Additional analyses including difference-in-difference, time series tests, interrupted time series regression analysis and Granger causality test were performed. RESULTS: A single change point was identified and occurred at week 16, 2020. For 2020, the median opioid overdose deaths numbers for weeks 1-16 and weeks 17-32 were 68.5 and 101, respectively. The opioid overdose deaths numbers from weeks 17-32 of 2020 were significantly higher than those in weeks 1-16 of 2020 and those in 2018 and 2019 (before and after week 16). The interrupted time series regression analysis indicated more than 203 deaths weekly for weeks 17-32 of 2020 compared to all other weeks. The result of the Granger causality test found that the identified change point (week 16 of 2020) directly influenced the increase in opioid overdose deaths in weeks 17-32 of 2020. CONCLUSION: The identified change point may refer to the timing of many factors, not only the economic payments and further research is warranted to investigate the potential relationship between the COVID-19 economic impact payments and overdose deaths.

Global Utilization Trends of Direct Acting Antivirals (DAAs) during the COVID-19 Pandemic: A Time Series Analysis.

The 2019 novel coronavirus (COVID-19) pandemic has placed a significant strain on hepatitis programs and interventions (screening, diagnosis, and treatment) at a critical moment in the context of hepatitis C virus (HCV) elimination. We sought to quantify changes in Direct Acting Antiviral (DAA) utilization among different countries during the pandemic. We conducted a cross-sectional time series analysis between 1 September 2018 and 31 August 2020, using the IQVIA MIDAS database, which contains DAA purchase data for 54 countries. We examined the percent change in DAA units dispensed (e.g., pills and capsules) from March to August 2019 to the same period of time in 2020 across the 54 countries. Interrupted time-series analysis was used to examine the impact of COVID-19 on monthly rates of DAA utilization across each of the major developed economies (G7 nations). Overall, 46 of 54 (85%) jurisdictions experienced a decline in DAA utilization during the pandemic, with an average of -43% (range: -1% in Finland to -93% in Brazil). All high HCV prevalence (HCV prevalence > 2%) countries in the database experienced a decline in utilization, average -49% (range: -17% in Kazakhstan to -90% in Egypt). Across the G7 nations, we also observed a decreased trend in DAA utilization during the early months of the pandemic, with significant declines (p < 0.01) for Canada, Germany, the United Kingdom, and the United States of America. The global response to COVID-19 led to a large decrease in DAA utilization globally. Deliberate efforts to counteract the impact of COVID-19 on treatment delivery are needed to support the goal of HCV elimination.

Futures-oriented drugs policy research: Events, trends, and speculating on what might become.

One concern in the field of drugs policy is how to make research more futures-oriented. Tracing trends and events with the potential to alter drug futures are seen as ways of becoming more prepared. This challenge is made complex in fast evolving drug markets which entangle with shifting social and material relations at global scale. In this analysis, we argue that drugs policy research orientates to detection and discovery based on the recent past. This narrows future-oriented analyses to the predictable and probable, imagined as extensions of the immediate and local present. We call for a more speculative approach; one which extends beyond the proximal, and one which orientates to possibilities rather than probabilities. Drawing on ideas on speculation from science and technology and futures studies, we argue that speculative research holds potential for more radical alterations in drugs policy. We encourage research approaches which not only valorise knowing in relation to what might happen but which conduct experiments on what could be. Accordingly, we trace how speculative research makes a difference by altering the present through making deliberative interventions on alternative policy options, including policy scenarios which make a radical break with the present. We look specifically at the 'Big Event' and 'Mega Trend' as devices of speculative intervention in futures-oriented drugs policy research. We illustrate how the device of Mega Trend helps to trace as well as to speculate on some of the entangling elements affecting drug futures, including in relation to climate, environment, development, population, drug production, digitalisation, biotechnology, policy and discourse.