Barriers to Care Experienced by Patients Who Inject Drugs During the COVID-19 Pandemic: A Qualitative Analysis.

OBJECTIVES: To identify the barriers to accessing health care and social services faced by people who inject drugs (PWID) during the coronavirus disease 2019 (COVID-19) pandemic.
METHODS: This report is a sub-analysis of a larger qualitative study. Semi-structured interviews were conducted with PWID admitted to an academic medical center from 2017 to 2020 for an invasive injection-related infection. Standard qualitative analysis techniques, consisting of both inductive and deductive approaches, were used to identify and characterize the effects of COVID-19 on participants.
RESULTS: Among the 30 PWID interview participants, 14 reported barriers to accessing health and addiction services due to COVID-19. As facilities decreased appointment availability or transitioned to telemedicine, PWID reported being unable to access services. Social distancing led to isolation or loneliness during hospital stays and in the community. Recovery meetings and support groups, critical to addiction recovery, were particularly affected. Other participants reported that uncertainty and fear of contracting the virus generated changes in behavior that led them to avoid seeking services.
CONCLUSIONS: COVID-19 has disrupted health systems and social services, leading PWID to experience unprecedented barriers to accessing and maintaining health and addiction services in both inpatient and outpatient settings. Opioid use disorder management must be understood as a holistic process, and a multidisciplinary approach to ensuring comprehensive care, even in the midst of this pandemic, is needed.

The coronavirus disease 2019 (COVID-19) pandemic has highlighted vulnerabilities in the health-systems designed to provide care to PWID with opioid use disorder. Even outside of the hospital setting, exacerbated emotional and financial stress, social isolation, and disconnection from support networks may erode individuals’ progress toward recovery and management of OUD. Diversion of health system resources toward the COVID-19 response has impeded access to medications to treat opioid use disorder (MOUDs),[1] HIV pre-exposure prophylaxis,[2] and harm reduction interventions such as syringe exchange programs.[3] Furthermore, preliminary data suggest that deaths from opioid overdoses across the country in 2020 are already outpacing rates from previous years.[4] There are limited data regarding the extent to which the COVID-19 pandemic has impacted persons who inject drugs (PWID) from their own perspectives. The present study seeks to address this by describing the ways in which PWID, in the context of the pandemic, have struggled to access and navigate services related to OUD harm reduction, treatment, or recovery.

METHODS

Between April and October 2020, we conducted 30 semi-structured interviews with patients who had been admitted to a 1400-bed, academic, tertiary care center in St. Louis, Missouri, for infections related to intravenous drug use over the preceding 2 years. This was part of an ongoing CDC-funded study.[5] Adults over 18 years of age hospitalized for a serious injection drug use-related infection (ie, endocarditis, osteomyelitis, septic arthritis, epidural abscess or S. aureus bacteremia) were eligible for participation. Each participant completed a phone interview ranging from 10 to 40 minutes. This study was approved by the Washington University Institutional Review Board.

Only interviews discussing the impact of the COVID-19 pandemic on PWID were included in the final analysis. This included interviews with patients who were hospitalized during the pandemic and with patients who had been hospitalized before 2020 but identified barriers to care within the community due to the pandemic. Interview transcripts were coded thematically using NVivo qualitative research software.[6] Thematic analysis drew from inductive and deductive approaches to identify and characterize instances of themes and patterns.[7] Two members of the research team (EG and NN) independently reviewed each audio recording and transcript to correct for errors. All transcripts were independently coded by these 2 researchers and discrepancies were rectified through discussion.

RESULTS

Of the 30 participants originally interviewed, 14 reported that COVID-19 had impacted their OUD recoveries or hospital experience. Participant demographics are in Table 1. Themes and associated quotes are outlined in Table 2 and described in the following paragraphs.

TABLE 1

Participant Characteristics

Characteristic	N	%
Sex
Male	9	64.3%
Female	5	35.7%
Age (at time of interview)
20–29	2	14.3%
30–39	6	42.9%
40–49	2	14.3%
50–59	2	14.3%
60–69	2	14.3%
Race/Ethnicity
White	7	50%
Black	6	42.9%
Hispanic/Latino	1	7.1%

TABLE 2

Impacts of the COVID-19 Pandemic on PWID

Theme	Quotes
Heightened barriers to health and addiction care access	The appointment that was set up for me, I couldn’t have got there, anyway, because the buses didn’t run that early to get me that far. Then, we had the whole scare, and the lock down. They sent people home to work out of their houses and I didn’t have those phone numbers. –62-year-old White male who used heroin and fentanylI do have hepatitis … I am supposed to be doing my follow-up. I have to get more lab works done, but since coronavirus, they’ve put that on hold. –38-year-old White male who used heroin, fentanyl, and methamphetamine[Interviewer: Are there resources in your community that would be useful for you?]There are, but everything is closed down right now. So, I guess I could answer no, there isn’t any, but it's just because of the COVID thing. –34-year-old White male who used heroin and marijuana
Decreased social support	Well, with the way the pandemic is going on, everything is basically shut down as far as meetings and the AA and things like that. So, I’ve just been using the methadone basically. –35-year-old African American male who used heroin and fentanylVisits [could have improved during my hospitalization experience] … they were restricted by that COVID. –52-year-old African American male who used heroin and fentanylI miss my family. And I don’t like being trapped in. I don’t like being in one place… something that need to change is, I wish I can get some visitors… But I’m just bearing with it because of the situation [COVID-19]. –36-year-old African American male who used opioids
Changes in behavior	I was on the mend … before the COVID outbreak, I was going to methadone clinic, but I had to rely on a ride. And ever since that virus, that just didn’t, it didn’t work out. –58-year-old White male who used heroin and fentanylThis is the first time in my lifetime I’ve gone through anything like this. I was petrified for my wife and daughter being out there by themselves. My wife lost her job. My daughter lost her job because they were locking it down. So, I didn’t think leaving five or six days early was that big a deal. –62-year-old White male who used heroin and fentanyl

COVID-19 indicates coronavirus disease 2019; PWID: people who inject drugs.

Heightened Barriers to Health and Addiction Care Access

Several participants reported that COVID-19 and subsequent restrictions led to new or increased barriers to accessing ambulatory OUD care, including primary care and MOUD clinics. Several reported longer appointment wait times or having to transition to telehealth visits. For participants whose facilities remained open, other barriers to accessing care were observed, including reduced hours or loss of transportation. A 29-year-old African American female who used fentanyl, heroin, and crack cocaine explained how the pandemic restricted her ability to access addiction resources in her community. When asked if she had adequate resources in her community she answered, “I did somewhat, but now it's so hard. The stipulations are so hard to get in. They make the appointments a month or 2 months away. I guess they’re overcrowded, so yeah, it's very difficult, it's like [just] self-motivation right now.”

Decreased Social Support

Social distancing measures designed to limit the spread of COVID-19 resulted in loneliness and isolation which complicated not only postdischarge recovery but also in-hospital treatment for invasive infections. Recovery meetings and support groups, important to maintaining sobriety and social connectedness, were curtailed or transitioned to a virtual format. A Hispanic female who used heroin, cocaine, marijuana, and alcohol described meetings as critical to her recovery. “But I can’t go nowadays… they’re closed because of the virus.” For patients hospitalized during the pandemic, the inability to receive visitors significantly impacted their experiences, leading some to discharge against medical advice (AMA). As a 42-year-old White female who used heroin, crack cocaine, methamphetamine, and marijuana described, “it was being alone [that made me want to leave]. I don’t like to be alone … I’m sitting in the hospital fighting this infection, fighting this addiction. I’m used to [my support people] always being there. Even if it's for a couple of hours, but I had to understand there's an epidemic going on in the world.”

Changes in Behavior

Despite physical barriers to accessing health care brought on by the pandemic, the threat of COVID-19 changed participants’ behaviors in a way that impacted their ability to access health services and addiction support. Several reported feeling wary to seek care for fear of contracting the virus in a clinical environment. Others described the threat of COVID-19 and its economic repercussions as leading them to discharge AMA from the hospital. A 62-year-old White male who used heroin and fentanyl described the pandemic as a more immediate concern than completing antibiotic treatment for his infection. “This is the first time in my lifetime I’ve gone through anything like this. I was petrified for my wife and daughter being out there by themselves. My wife lost her job. My daughter lost her job because they were locking it down. So, I didn’t think leaving 5 or 6 days early was that big a deal.”

DISCUSSION

Our study identified several barriers to retention in inpatient care for invasive infections, in addition to accessing and navigating health and addiction services postdischarge due to COVID-19. Our findings support concerns that social distancing and strained health systems have significantly impacted PWID and posed unique challenges to ensure they receive consistent and accessible care throughout the pandemic.[1,8,9] Much of the discourse surrounding the intersections of the opioid and COVID-19 public health crises has focused on MOUD regulations.[10] Measures taken at the onset of the pandemic by the US Department of Health and Human Services and the Drug Enforcement Agency enabled providers to rapidly transition to telemedicine to treat OUD.[11,12] However, this study indicates that other gaps in health and addiction services caused by the COVID-19 pandemic remain unaddressed.

As social service programs slowed and treatment centers reduced services in the face of financial strain,[13] PWID described unique challenges to receiving medical care, addiction services, and social support. Health concerns deemed nonurgent in light of the acute risk of COVID-19 have been postponed, and recovery meetings were canceled or transitioned to a potentially undesirable virtual format. Participants also reported that social isolation and reduced social support during hospitalizations led to AMA discharge. Participants included those from the St. Louis metropolitan region and rural Missouri, demonstrating COVID-19-related barriers affect both rural and urban environments.

It has been long accepted that addiction care should be holistic, including medical and behavioral health treatments. Early in the COVID-19 pandemic, there was emerging guidance on how to safely implement essential services. Now, more than a year into the global crisis, there are clear recommendations about how to safely deliver care and operate essential services.[14,15] Though recent legislative efforts are working to relax barriers to prescribing MOUDS,[16] our data suggest that this is only 1 part of the addiction care patients require. It will be important moving forward to restore not only access to MOUDS, but also supportive and mental health services. This may require inventive solutions (such as outdoor meetings) or the provision of technologies to aid in the distanced provision of services (ie, access to internet-connected devices).

This study has limitations. Most notably, it identified themes surrounding COVID-19 that emerged within a larger investigation; COVID-19 was not explicitly addressed in the interview guide. We therefore may have missed opportunities to fully assess the pandemic's impact upon participants. Further studies on a larger scale are needed to document the barriers to care experienced by PWID during the pandemic and fully inform potential interventions.

CONCLUSIONS

The COVID-19 pandemic has resulted in unprecedented disruption of healthcare services. Although access to MOUDs has been liberalized, patients in both inpatient and outpatient settings suffered due to a decrease in access to counseling, group support, and harm reduction services. There is robust and ever-increasing guidance for the safe resumption of essential services. Addiction treatment providers should strive to return access to services in a safe and timely manner.