Coronavirus disease 2019 (COVID-19) is taking a devastating toll globally. As of May 2020, there have been 76 000 cases of COVID-19 confirmed in Canada, including 2446 cases and 146 deaths in British Columbia. The emergence of COVID-19 is concerning in BC, where an ongoing public health emergency was declared in April 2016 related to high rates of drug overdose deaths. In the past 4 years, more than 5000 illicit drug toxicity deaths have been reported in BC.[1] COVID-19 disproportionately affects people who use substances, including risk of transmission, severity of outcome of novel coronavirus (SARS-CoV-2) infection, and drug overdose risk.

How are people who use substances impacted by COVID-19?

People who use substances are often socioeconomically marginalized and precariously housed, and may, therefore, be unable to physically distance and maintain hand sanitation. Congregate living environments such as shelters, supportive housing, and single-room occupancy hotels can exacerbate SARS-CoV-2 transmission risk, as has been seen in Toronto where more than 300 cases were identified in shelters.[2] Furthermore, people who use substances are disproportionally affected by chronic conditions that increase susceptibility to severe COVID-19 outcomes, such as chronic pulmonary and coronary heart disease.[3]

Measures to address COVID-19 may place people who use substances at increased risk of drug overdose. Drug markets have become volatile due to border and travel restrictions and limited availability of precursor chemicals, creating a more unpredictable and toxic drug supply. Drug testing services have reduced capacity and are not equitably distributed across the province, thus making it difficult to determine implicated substances and issue meaningful community alerts.

Overdose deaths increased 61% across BC in March 2020 compared to February 2020.[1] The cause of this resurgence in overdose fatalities and the extent to which COVID-19 is implicated has yet to be fully determined. However, reduced access to harm reduction services, including observed consumption sites, increased drug toxicity, and changes to individual drug use practices and settings are amplifying the already high risk of overdose in BC.

Supporting people who use substances

People who use substances are more likely to die from overdose than COVID-19. Thus, it is imperative to support safer substance use by encouraging use of observed consumption sites, which are designated essential clinical services, and using with others at a safe distance. In addition, individuals should be equipped for overdose response. Online take-home naloxone training is available at www.naloxonetraining.com [13], and take-home naloxone kits are available from over 1500 sites throughout BC, including 700 community pharmacies. Patients should be counseled to use additional doses of naloxone as required to reduce the need for additional resuscitative procedures. Harm reduction recommendations, like using small test doses of substances and accessing new pipes and needles, will help patients avoid both overdose and SARS-CoV-2 transmission.

Supporting individuals with opioid and other substance use disorders is a priority at this time. Lack of access to substances due to physical distancing and quarantine orders can put individuals at risk of withdrawal. Physicians must recognize clinic and emergency department visits and telemedicine consultations as opportunities to connect patients with counseling, mental health, and social housing options, and to provide safer alternatives to the illicit drug market. This includes offering a range of opioid agonist therapies (for buprenorphine/naloxone, observed or take-home inductions, standard and microdosing options), and safely providing patients with missed opioid agonist therapy doses or prescription refills and referrals to addictions specialists. Additionally, recent BC risk mitigation guidelines recommend that health care providers offer pharmaceutical replacements for illicit substances.[4]

COVID-19 is impacting the mental health and well-being of people who use substances as they navigate increased isolation compounded with ongoing trauma caused by the overdose crisis. Physicians have an important role in supporting people with substance use disorders as they strengthen their resilience and rebuild connections in the next phases of COVID-19. 
—Jane Buxton, MD
Medical Lead for Harm Reduction, BCCDC
—Jessica Moe, MD
Assistant Professor, Department of Emergency Medicine, UBC
—Kristi Papamihali, MPH
Epidemiologist for Harm Reduction, BCCDC
—Margot Kuo, MPH
Epidemiologist for the Overdose Emergency Response Centre, Ministry of Mental Health and Addictions and BCCDC

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This article is the opinion of the BC Centre for Disease Control and has not been peer reviewed by the BCMJ Editorial Board.

References

1.    British Columbia Coroners Service. Illicit drug toxicity deaths in BC: January 1, 2010 – March 31, 2020. Accessed 18 May 2020. www2.gov.bc.ca/assets/gov/birth-adoption-death-marriage-and-divorce/deaths/coroners-service/statistical/illicit-drug.pdf [14].

2.    COVID-19: Status of cases in Toronto. Active COVID-19 outbreaks in shelters and respite sites. Acces­sed 18 May 2020. www.toronto.ca/home/covid-19/covid-19-latest-city-of-toronto-news/covid-19-status-of-cases-in-toronto [15].

3.    Slaunwhite AK, Gan WQ, Xavier C, et al. Overdose and risk factors for severe acute respiratory syndrome. Drug Alcohol Depend 2020:108047.

4.    British Columbia Centre on Substance Use. Risk mitigation in the context of dual public health emergencies: Interim clinical guidance. March 2020. Accessed 18 May 2020. www.bccsu.ca/wp-content/uploads/2020/04/Risk-Mitigation-in-the-Context-of-Dual-Public-Health-Emergencies-v1.5.pdf [16].