Home > Substance use-related harms and risk factors during periods of disruption.

Ontario Agency for Health Protection and Promotion (Public Health Ontario). (2020) Substance use-related harms and risk factors during periods of disruption. Toronto: Queen's Printer for Ontario.

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This review focuses on the changes in substance use-related harms experienced by people who use substances (e.g., fentanyl, cocaine) during periods of disruption. Changes in substance use-related harms in this population, and harms related to alcohol, tobacco, and cannabis were out of scope for this rapid review. We define periods of disruption to include any disruption caused by infectious disease, natural disasters, disasters (e.g., terrorism, fires), war, service closures, or other emergencies that affect the social structures and supports for people who use substances. We recognize that some of these disruptions represent a discrete event (e.g., terrorist attack) and some represent a more prolonged event (e.g., COVID-19 pandemic, war). Further, responses to the event differ and may lead to different impacts (e.g., emphasis on people distancing during COVID-19). 

Key findings:

  • Evidence on substance use-related harms and relevant risk factors during periods of disruption, is limited and results varied. Few studies reflected the voices and experiences of people who use drugs, considered inequities, or examined intersecting determinants of health for people who use substances.
  • Relevant records were based on Hurricane Sandy, Hurricane Katrina, the September 11 terrorist attacks, a heroin shortage, closure of a needle and syringe program, and the Coronavirus Disease 2019 (COVID-19) pandemic. Disruptions prior to the COVID-19 pandemic did not involve specific measures to distance people from each other. 
  • The most commonly cited substance use-related harms were fatal and nonfatal drug poisoning. In the current context, while evidence on the impacts of COVID-19 disruptions are not fully known, preliminary reports indicate an increase in fatal drug poisoning is occurring.
  • The main risk factors for increased substance use-related harms reflected a disruption in ways that people typically manage their drug use and access a network of support. This included decreased availability and increased price of drugs, decreased access to substance use treatment, harm reduction services and other supports, and increased toxicity of the drug content.
  • Monitoring and timely reporting of fatal and nonfatal poisoning, along with knowledge based on living and lived expertise of substance use, community experience, and practice are essential to understand the impacts of COVID-19 community-based public health measures and to inform response strategies.

Rapid review: strategies to mitigate risk of substance use-related harms during periods of disruption.

Key findings:

  • Periods of disruption threaten the continuity of essential harm reduction, substance use treatment, and other services for people who use substances. Services should develop or update contingency plans in advance and receive supports during periods of disruption to ensure services are maintained.
  • Physical distancing and infection prevention and control measures were commonly suggested to allow for service continuity in the context of Coronavirus Disease 2019 (COVID-19). However, COVID-19 public health measures may limit services for people and guidance on mitigating this impact on people who use substances and overdose response was scarce.
  • Service coordination, integration, and program adaptations should be considered to ensure access to a variety of harm reduction services and approaches that meet the specific and changing needs of people who use substances during COVID-19.
  • Treatment services should consider systems for communication of care plans as a strategy to ensure continuity of care during disruptions, and as well as processes specific to opioid agonist treatment visits, prescribing, and medication access.
  • There is limited evaluative evidence on the effectiveness and implementation of the strategies or guidance in the context of disruption, and support for rapid evaluation is needed. Considerations of equity and intersecting social determinants of health that produce substance use-related harms and engagement with people who use drugs should be prioritized in the planning, design, and delivery of emergency planning and mitigation strategies.

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