April 12, 2021

At a crossroads: The intersecting public health emergencies of COVID-19 and the overdose crisis in BC [1]

The overdose crisis, declared a public health emergency in BC in 2016, has worsened due to the COVID-19 pandemic.[1,2] As of October 2020, the number of overdose deaths among people who use drugs was at an all-time high in BC.[3] This increase is due, in part, to pandemic guidelines that neglect the needs of people who use drugs, who are at great risk for overdose and death.[4,5] For example, BC’s public health orders regarding social distancing and self-isolation are contradictory to instructions given to people who use drugs about never using drugs alone.[6] The question now is how can public health officials manage the overdose crisis while also mitigating the COVID-19 pandemic?

British Columbia has some of the highest per-population rates of overdose deaths across Canada.[7] From January 2020 to October 2020, BC recorded 1386 illicit drug overdose deaths, which was the highest number of overdose deaths ever reported in BC for this 10-month period.[8] Although this year has seen a decrease in the number of overdose deaths occurring indoors, this has been offset by increased deaths in outdoor settings (11.9% in 2019 to 14.9% in 2020).[8] Likely due to physical-distancing orders, people are more often using drugs alone in outdoor settings where overdose events might not be noticed in time for lifesaving naloxone treatment or resuscitation to be initiated.[9] People who use drugs are effectively forced to choose between two contradicting public health guidelines: do they use alone and risk overdose death, or do they use with others and risk contracting COVID-19?

With the borders closed, regular channels to accessing street drugs have been disrupted.[10] For people who use drugs, this means buying from newer, riskier suppliers, as well as uncertainty in the contents of their drug supply. Despite this, drug testing and overdose prevention facilities are still inaccessible or operate at limited capacity. These barriers have detrimentally affected individuals who rely on the provision of these lifesaving services.[4] Indeed, heavily contaminated drug supplies have been attributed to the increase in overdose deaths in BC since the onset of the pandemic.[7] Extreme fentanyl concentrations of 50 ug/L or greater were implicated in at least 14% of all overdose deaths in BC since the start of the pandemic.[8] This is in stark contrast to 8% of overdose deaths between January 2019 to March 2020.[8]

To address the overdose crisis in the context of the COVID-19 pandemic, we must shift our attention to the pandemic guidelines that are putting people who use drugs at risk for overdose death in BC. Strict physical distancing orders coupled with the termination of overdose prevention services almost certainly contributed to the increased number of overdose deaths in BC this year.[5,6] People who use drugs are faced with the challenge of having to balance pandemic guidelines with overdose prevention measures. This is an unnecessary trade off that can be resolved by improving existing pandemic guidelines so that protective factors against overdose death are propagated, and evidence-based COVID-19 prevention strategies are retained.[11] This includes ensuring that people who use drugs have accessible drug testing and overdose prevention services. In addition, there is a need for clear and tailored messaging on how to safely use drugs to minimize COVID-19 transmission. Furthermore, we must apply and test evidence-based strategies to minimize the risk of overdose deaths among people who use drugs. For example, decriminalization of personal drug use and the provision of safer drug supplies in individualized care plans are recommendations, among others, that can contribute to reduce the impact of the overdose crisis in Canada.[12] These approaches certainly have merit in the face of issues brought on by the COVID-19 pandemic. Programs and policies such as the ones described need to be considered if we are to lessen the impacts of this public health emergency.

The overdose crisis in BC has been exacerbated by the COVID-19 pandemic. Despite BC reporting over 1300 overdose deaths since the onset of the pandemic, progress in managing the overdose crisis has been ineffectual. To save the lives of people who use drugs affected by these dual public health emergencies, policy makers must work toward developing pandemic guidelines that are both conducive to the needs of people who use drugs, and reflective of COVID-19 control strategies in BC.
—Rajan Bola, BSc
School of Population and Public Health, University of British Columbia
—Eugenia Oviedo-Joekes, PhD
School of Population and Public Health, University of British Columbia
Centre for Health Evaluation & Outcome Sciences, Providence Health Care, St. Paul’s Hospital

References

1. Bedford J, Enria D, Giesecke J, et al. COVID-19: Towards controlling of a pandemic. Lancet 2020;395:1015-1018.

2. Smolina K, Crabtree A, Chong M, et al. Patterns and history of prescription drug use among opioid-related drug overdose cases in British Columbia, Canada, 2015–2016. Drug Alcohol Depend 2019;194:151-158.

3. BC Centre for Disease Control. Overdose response indicators, 2020. Accessed 30 November 2020. www.bccdc.ca/health-professionals/data-reports/overdose-response-indicators [2].

4. Tyndall M. Safer opioid distribution in response to the COVID-19 pandemic. Int J Drug Policy 2020;83:102880.

5. Dunlop A, Lokuge B, Masters D, et al. Challenges in maintaining treatment services for people who use drugs during the COVID-19 pandemic. Harm Reduct J 2020;17:26.

6. Schlosser A, Harris S. Care during COVID-19: Drug use, harm reduction, and intimacy during a global pandemic. Int J Drug Policy 2020;83:102896.

7. Belzak L, Halverson J. Evidence synthesis—the opioid crisis in Canada: A national perspective. Health Promot Chronic Dis Prev Can 2018;38:224-233.

8. British Columbia Coroners Service. Statistical reports on deaths in British Columbia. Accessed 20 November 2020. www2.gov.bc.ca/gov/content/life-events/death/coroners-service/statistical-reports [3].

9. MacKinnon L, Socías ME, Bardwell G. COVID-19 and overdose prevention: Challenges and opportunities for clinical practice in housing settings. J Subst Abuse Treat 2020;119:108153.

10. United Nations Office on Drugs and Crime. COVID-19 and the drug supply chain: From production and trafficking to use. Accessed 13 January 2021. www.unodc.org/documents/data-and-analysis/covid/Covid-19-and-drug-supply-chain-Mai2020.pdf [4].

11. Heimer R, McNeil R, Vlahov D. A community responds to the COVID-19 pandemic: A case study in protecting the health and human rights of people who use drugs. J Urban Health 2020;97:448-456.

12. Oviedo-Joekes E, MacDonald S, Boissonneault C, Harper K. Take home injectable opioids for opioid use disorder during and after the COVID-19 pandemic is in urgent need: A case study. Subst Abuse Treat Prev Policy 2021;16:22-27.