Nanky Rai is a harm reductionist and a primary care physician at Parkdale Queen West Community Health Centre; she works closely with people who use drugs and those experiencing homelessness.

Malika Sharma is an infectious disease physician in Toronto, specializing in the care of people living with HIV, and an assistant professor at the University of Toronto.

Picture of Nanky Rai and Malika SharmaWe are currently experiencing unprecedented restrictions on public life. For many, the impact of these policies ranges from major inconvenience to life-changing. However, as physicians involved in caring for people experiencing homelessness and an overdose crisis, we worry that the impacts may be life-threatening.

Many people who use drugs rely on supervised consumption sites to avoid overdose and access healthcare. While supervised consumption sites in Ontario have seen their budgets slashed, our Jan-Sept 2019 overdose death rates have surpassed British Columbia. Last month, Toronto paramedics responded to 345 overdose calls and 19 fatalities. Whether it is COVID-related anxiety or diminished access to healthcare, people who use drugs are at heightened risk for bad health outcomes during this pandemic. The call to self-isolate puts people in a uniquely dangerous position. This, along with limited access to public spaces and fear of policing further, limits access to safe equipment and overdose prevention strategies, putting people at risk for infections and overdose deaths.

Supervised consumption sites must not only remain open, but need to expand to meet growing needs. We need to ensure that frontline workers in supervised consumption sites, drop-ins, respites and shelters have access to personal protective equipment and can enact physical distancing protocols. Communication between hospitals and these spaces needs to be frequent and transparent. An urgent task force needs to be created where decision-makers listen to and take direction from frontline workers and people with lived/living experience of homelessness and drug use. This task force must include adequate representation of Indigenous and Black community members who are disproportionately impacted by institutional racism, which is only heightened during pandemics.

We also need to lower the risk of overdose through greater access to safer supply harm reduction programs.  Safer supply programs are championed by providers across Canada, including the London InterCommunity Health Centre. With support and guidance from governments and healthcare institutions, such as the British Columbia Centre on Substance Use guidelines for prescribers, safer supply programs can be implemented by prescribers across the country.

Many people who use drugs also experience homelessness. Crowding in shelters can lead to the rapid spread of infectious diseases. Toronto has leased contracts for 300 hotel rooms in an effort to facilitate physical distancing, but this is not enough for a city with over 7000 people relying on the shelter system. We also know that uptake will be limited until processes for referral are transparent and until people are well supported and reassured that their health and substance use needs will be addressed in these new spaces. Many other so-called ‘dry’ shelters remain inaccessible, demanding abstinence in exchange for accommodation. As we work to expand temporary and long-term housing, it is critical that people who use drugs are not left behind. We need to plan both temporary and long-term sustainable housing solutions – to not only mitigate risks in this current pandemic, but in any future ones.

Lastly, we must recognize that the pandemic and public health measures to address it will impact people differently – particularly people who have been, and continue to be, traumatized by our healthcare and policing institutions. People who use drugs are being instructed to keep a two-week supply of drugs on hand to avoid withdrawal; this is invariably riskier for Black and Indigenous people, who are at higher likelihood of being arrested or stopped by police. Decriminalizing personal drug use is not only imperative during this pandemic, it’s a necessary public health response to the overdose crisis. Yet, rather than supporting people’s substance use needs, hospitals and other institutions may resort to measures that can rob patients of autonomy, like restraints or policing, in their attempts to enforce isolation and protect public health. Involving people who use drugs, who are experiencing homelessness and who are impacted by structural racism, is key to ensuring that public health measures are enacted in ways that protect those most affected by this pandemic while maintaining dignity and respect.

Over 14,000 people have died of opioid overdose in Canada from January 2016 to September 2019. Fewer than 3000 individuals have died of COVID-19. As our healthcare and political systems respond to a surge in cases and double efforts to “flatten the curve,” we must consider how these policies affect some of the most marginalized members of our communities. We have to listen to what people with lived experience are calling for and be prepared to act.