In marginalized populations, the coronavirus disease 2019 (COVID-19) pandemic has exacerbated pre-existing issues while presenting new challenges. Findings have indicated that COVID-19 has had a more pronounced negative impact on economic and work-related factors in women, racial and ethnic minorities, and low-income workers.1

For people who use drugs (PWUD), illicit drug use behaviors may become even riskier due to COVID-related circumstances, adding to the burden of infectious disease and overdose risk. A recent study demonstrated a surge in overdose-related cardiac arrest reported in a national emergency medical services database, with rates that have been roughly 50% higher during pandemic months compared to pre-pandemic rates.2 

Social distancing requirements may increase the likelihood of people using drugs alone, which is associated with an increased risk death due to an overdose. Meanwhile, tightened international border restrictions have increased the variability and potential toxicity of the illicit drug supply. In addition, there has been less access to harm reduction and addiction treatment services since the pandemic began.3

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The convergence of these public health emergencies (increasing overdose rates, COVID-19) with the ongoing risk of HIV and hepatitis C virus infections among PWUD represents a growing syndemic, according to research published in the Journal of Studies on Alcohol and Drugs.3 A syndemic can “worsen or accelerate disease progression and social outcomes,” wrote Matthew Bonn of the Canadian Association of People Who Use Drugs in Nova Scotia and researchers from several Canadian universities.

While noting the need to scale up existing services, including syringe distribution services, take-home naloxone, and addiction treatment, study authors proposed that innovative approaches are needed to effectively prevent overdose deaths and infectious diseases in PWUD. They stated that the impact of the syndemic on PWUD could be reduced through the implementation of compassionate responses including decriminalization of personal drug use.

These steps would result in lower rates of medical complications compared to those associated with the criminalization of drug use, while also reducing stigma and increasing timely access to healthcare services including harm reduction services and substance abuse treatment. Such efforts may also reduce the risk of incarceration and help to prevent further spread of COVID-19 in correctional facilities.

Another suggested measure is the provision of a safe supply of pharmaceutical-grade drugs such as hydromorphone, diazepam, methylphenidate, and diacetylmorphine to PWUD. Pointing to the high rates of overdose deaths related to illicit fentanyl and fentanyl analogues, having “access to pharmaceutical-grade drugs would ensure that they are appropriately dosed and not adulterated, allowing PWUD to reduce their risk of unintentional overdose from a toxic illicit drug supply,” wrote Bonn et al. They discussed the need to address various barriers to decriminalization, including conflicts with standard provider prescribing practices.

“This pandemic is not only a public health crisis but also a chance to develop and maintain equitable and sustainable solutions to the harms associated with the criminalization of drug use,” the authors concluded.

For an additional perspective on the topic, we interviewed Anna Lembke, MD, associate professor and medical director of addiction medicine in the department of psychiatry and behavioral sciences at the Stanford University School of Medicine in California. Dr Lembke wrote a commentary on the paper by Bonn et al, which was published in the same journal issue.4

This article originally appeared on Infectious Disease Advisor