On Mondays, Dr. Kimberly Sue would see patients at a syringe service program on the Lower East Side in New York, prescribing medications like buprenorphine that treat opioid addiction. Other days, she saw patients at Rikers Island Correctional Health Services, where she specialized in treating HIV and substance use disorders. She was practicing medicine on the front lines of the nation’s overdose crisis until the Covid-19 pandemic slammed New York.
“I knew there weren’t going to be enough doctors,” she said. Sue spent most of April treating Covid-19 patients at Billie Jean King Tennis Center, which was turned into a makeshift hospital during the pandemic. In addition, she continued to see her substance use disorder patients, prescribing medication refills remotely via telehealth visits. “I also initiated buprenorphine for people who started using opioids during the pandemic as a response to anxiety and stress,” she said. (Both buprenorphine and methadone are considered the gold standard for treating opioid use disorder.)
The temporary hospital has since closed, but Sue still feels she’s caught between two largely preventable public health disasters. “There’s a lot of anxiety brewing, people are really craving face-to-face interaction and stability,” Sue said. “I’m extremely taxed, my patients are extremely taxed.”
Before the pandemic took hold, overdose deaths hit a national record of almost 71,000 in 2019, according to preliminary data compiled by the Centers for Disease Control and Prevention and published last week. The highest peak yet comes on the heels of a meager 4.1 percent decline in overdose deaths in 2018, at the time celebrated by President Trump as “tremendous” progress. That flimsy and fragile achievement has rapidly unraveled, and by all indicators, overdose deaths are on track to get even worse in 2020. Anecdotal reports and local data illustrate an alarming spike in overdoses since stay-at-home orders were issued in March.
As more than 35 states report increases in overdose deaths since the start of the pandemic, harm reduction workers are pointing to a failed state response as the foundation of the crisis: massive unemployment and financial precarity, exacerbated housing insecurity as eviction moratoriums expire, slashed Medicaid budgets and addiction treatment services.
“Any gains we made in funding for health departments, syringe exchanges, naloxone distribution, safe consumption spaces, and community outreach—it’s all at risk from Covid,” said Sue, who is also medical director at the Harm Reduction Coalition, a nonprofit advocacy group. “The cuts are gonna happen, it’s all on the line.”
In addition to looming and long-standing cuts to vital health services, the practice of social distancing runs against one of the central tenets of safety when using drugs: Never use alone. The greatest resource available to harm reductionists and people who use drugs is access to one another, finding safety in a nonjudgmental and compassionate community. What does overdose prevention and harm reduction look like when people are more isolated than ever? Or when the public and private infrastructures that made the work possible are at risk of collapsing under austerity regimes? Even the most effective harm reduction strategies can only accomplish so much in a society that slashes investments in health, housing, and other basic needs.
Before he stopped using in 2017, Mike Brown injected meth and opioids for over 15 years. For a while after that, he worked as a “recovery advocate,” trying to connect people struggling with addiction to treatment centers that could offer help, but grew disillusioned with what he saw as a predatory system. “After about a year of doing that, I started seeing how shady the industry is,” he said. “They don’t give a shit about the patient, all they’re worried about is the insurance money.”
This was around the same time that Brown started hearing the term “harm reduction.” “When I first heard about syringe exchanges, I just couldn’t wrap my head around it,” he said, referring to programs that provide sterile syringes and collect used ones from people who inject drugs. “I thought, ‘Oh, that’s just enabling people to use,’ but then when you start looking at the evidence, it’s clear that it works.” Harm reduction is both a movement and a philosophy aimed at helping people who use drugs survive by giving them tools to prevent blood-borne infections and prevent and reverse overdoses.
Two years ago, Brown set up a small harm reduction outpost in Midland, Michigan, a mostly white, middle-class town of 41,700 people. As part of this work, Brown started Never Use Alone, a harm reduction service that connects people who have no choice but to use alone to a volunteer operator who waits on the line while the caller uses and calls for help if something goes wrong. Things started off slow, he said, with a few calls a week.
“Then this pandemic hit, and we’re getting 15 to 20 calls a day now,” Brown said, though he thinks skepticism about the service is keeping it from growing more at a time when people are limiting social interactions and using in isolation. Even though the service explicitly asks for the number to local emergency services instead of 911, which often dispatches police to the scene, calling for help still risks criminalization. “I don’t know if I would’ve trusted a service like this when I was using,” Brown said, though he’s hopeful the service will continue to grow as more people who use it vouch for it.
The overdose prevention line started by Brown seeks to offer some of the safety measures provided by supervised consumption sites, where people use drugs in sterile environments that are monitored by health professionals trained to reverse overdoses. There are about 100 supervised consumption sites in operation across Australia, Europe, and Canada, but the U.S. federal government publicly opposes consumption sites, going so far as to sue a nonprofit in Philadelphia for trying to open one. The local politics around their potential opening aren’t much more welcoming. In 2019, a federal judge in Philadelphia ruled that such a site would not violate an obscure statute in the Controlled Substances Act, but in June the same judge cited the pandemic and protests against police brutality as reasons to pause the opening.
“Given that sheltering in place during Covid-19 is increasing overdose mortality, safe consumption sites are more timely than ever,” Alex Kral, an epidemiologist at the nonprofit RTI International, told me. In The New England Journal of Medicine, Kral and his colleagues recently published a five-year evaluation of an unsanctioned consumption site operating at an undisclosed location in the United States. “In total, there were 10,514 injections and 33 opioid-involved overdoses over five years, all of which were reversed by naloxone administered by trained staff. No person who overdosed was transferred to an outside medical institution, and there were no deaths,” according to the study.
Brown’s overdose hotline is much more risky than a brick-and-mortar consumption site, and he acknowledges the inherent risks. “It’s a scary situation sometimes,” Brown says about being on the other end of the calls. “I took a call about an hour ago, and the guy said he was using a huge shot with heroin and fentanyl. I said, ‘Man, you gotta be careful, we can’t guarantee your safety here.’ He did the shot and started going out on me. Finally, just as I was about to pick up the other phone to call for help, he came back and got himself together.… My heart was pounding.”
“We’ve always had a lot of meth here in Denver,” said Kat Humphries, who works at the Harm Reduction Action Center, a syringe exchange and drop-in site in Denver. She keeps a close eye on self-reported overdose reversal data among her participants and saw a 46 percent spike between data tracked from January through March to data tracked from April through June.
“We’re seeing overdoses here skyrocket,” Humphries said. “Social distancing, people using alone, people who are homeless having no place to go—all of that is contributing to it. There’s also a lot of polysubstance use going on right now. People are combining heroin with benzos and alcohol—downers on downers on downers. We’re in the middle of a fucking pandemic, the most stressful thing.”
A lack of vital services and a broken safety net is also impacting people in upstate New York, Alexis Pleus, who founded a harm reduction education organization called Truth Pharm after her oldest son died of an overdose in 2014, told me. “It’s been an awful experience,” she said. “Ninety percent of our clients are on Medicaid or no insurance, folks who are in financial dire straits.” Where Pleus works in Broome County, New York, she says one of the most pressing issues during the pandemic is people losing housing. In just one month, Pleus said her organization spent more than $4,500 to get people into hotel rooms. “We don’t care if you’re using drugs, we just want to make sure you have your basic needs met.”
Thinking about what the pandemic has done to her patients, Dr. Sue said she feels “gloomy” and “despondent.” The syringe program where she used to see patients is closed, and people are craving interaction and the stability and structure of simply having a place to go. “Many people who are essential workers or were furloughed were already scraping by before this,” Sue said. “People tapped into their savings for a while, but now they’re in very vulnerable spots.”
Just as public health experts know what it takes to contain the spread of infection, the harm reduction movement knows how to prevent overdose deaths. But on both fronts, experts calling for an aggressive response are dismissed, and effective interventions are politicized and dogged by misinformation. “Other countries were able to resolve this, and we have an unending future,” Sue said. “It’s a political failure. Other countries have reined this in, and we have not. It’s very frustrating.” The coronavirus continues to spread uncontained in the U.S., and overdose deaths continue to soar at a rate that has decreased the average life expectancy for Americans. The fractures in American life have only gotten deeper since the pandemic hit.
Unless Congress intervenes, things could get even worse in the near future. More than 25 million Americans are on track to lose $600 a week in federal unemployment benefits, which has been a lifeline for those who are out of work during the pandemic. Eviction protections are expiring, and housing advocates warn of a “tsunami of evictions” for millions of families who cannot make rent. Other cuts to Medicaid, syringe services, and local health departments in response to the pandemic could result in fewer people accessing life-saving services. One public health emergency is exacerbating the other, and there’s no real end in sight.
One of the hardest things in all of this, Sue said, is thinking about the future. “We can’t see the horizon, we can’t envision when we will emerge from this.”