Matthew Bonn , a,* Adam Palayew , M.Sc.,b Sofia Bartlett , Ph.D.,c Thomas D. Brothers , M.D.,d Natasha Touesnard , a & Show All...
*Correspondence may be sent to Matthew Bonn via email at: firstname.lastname@example.org.
Abstract People who use drugs (PWUD) face concurrent public health emergencies from overdoses, HIV, hepatitis C, and COVID-19, leading to an unprecedented syndemic. Responses to PWUD that go beyond treatment—such as decriminalization and providing a safe supply of pharmaceutical-grade drugs—could reduce impacts of this syndemic. Solutions already implemented for COVID-19, such as emergency safe-supply prescribing and providing housing to people experiencing homelessness, must be sustained once COVID-19 is contained. 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 syndemic argumentThe criminalization of personal drug use marginalizes people who use drugs (PWUD), affecting their life, liberty, and security. Prohibition forces PWUD to engage in illegal activities to procure and consume drugs. This creates an international underground economy that generates billions of dollars despite escalating enforcement efforts (United Nations Office on Drugs and Crime, 2020b). This foments an environment in which drugs have inflated prices and unpredictable content, are potentially toxic, and are often consumed in unsafe ways. Along with deaths caused by the unintentional consumption of toxic drugs, there are also severe social punishments for drug use, such as being unemployed due to a low-level drug possession charge and/or being denied housing because of a criminal record, resulting in persistent homelessness. These conditions greatly increase the risk of overdose and overdose deaths, as well as injection-related infections—including HIV and hepatitis C virus (HCV)—while pushing PWUD away from the traditional health care system (Csete et al., 2016).
The coronavirus disease-2019 (COVID-19) pandemic, and the associated public health response of social distancing, physical isolation, and international border restrictions, creates greater harms for PWUD who rely on an illicit drug supply (United Nations Human Rights Office of the High Commissioner, 2020). Without a regular supply of drugs, PWUD are less able to physically isolate and will need to travel to obtain funds or purchase drugs. Physical isolation leads to using drugs alone, which increases the risk of overdose death. Many harm reduction and addiction treatment services have had to scale back based on social distancing guidelines (Bartholomew et al., 2020; Dunlop et al., 2020). International border restrictions related to COVID-19 have made the illicit drug supply even more unpredictable and deadly (Canadian Centre for Substance Use & Addiction & Canadian Community Epidemiology Network, 2020; United Nations Office on Drugs and Crime, 2020a).
As a consequence, PWUD face concurrent public health emergencies (United Nations Office on Drugs and Crime, 2019): increasing overdoses, HIV, HCV, and COVID-19. The confluence of these factors is leading to an unprecedented syndemic. A syndemic occurs when multiple health and social issues intersect and interact to worsen or accelerate disease progression and social outcomes (Singer et al., 2017; Tsai et al., 2017). Health issues such as HIV and HCV overlap with each other because they share similar routes of transmission and risk factors, and multiple social issues frequently co-occur with these infections, such as poverty, homelessness, and injection drug use (Butt et al., 2017; Cleland et al., 2017; Morano et al., 2013). For example, among people living with HCV infection, HIV co-infection accelerates liver disease progression. Poverty and homelessness are frequently found to reduce the likelihood of HIV antiretroviral medication adherence, so when HIV/HCV coinfection, poverty, and homelessness co-occur, they result in accelerated disease progression and poorer health outcomes (Klein et al., 2013).
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