Addressing the drug problem in health and social care will produce better outcomes. The review shows that one of the essential steps in policy design is to alter the government approach in managing the drug problem. Drug policy has been considered a criminal justice issue for many decades. Today, it has been acknowledged that the system is not able to produce the best results.

Read more here:
http://www.julkari.fi/bitstream/handle/10024/140116/URN_ISBN_978-952-343-504-9.pdf?sequence=1&isAllowed=y

COVID-19 and harm reduction in Greece – observations from inside the scenery

Background
To begin with,  we have to consider the condition of the general context which is the social-economic and the cultural one in Greece. A society extremely individualised after all where the vulnerable became more vulnerable and the middle class was smashed. It was not a coincidence that along with the austerity measures, literally at the same time ten years before two synthetic substances appeared in the open drug scene and changed the scenery. Poor quality of a type of methamphetamine called ‘sisa”(Arabic name for pipe) and a synthetic only for injection opiate called in the streets”thai”. These drugs came to stay along with the feeling of the constant emergency that penetrated all ranks of the Greek society except the super-rich of course. After ten years of austerity measures there was a wave of some kind of hope, the pandemic came and erased that wave. When the lockdown happened the street drug users without the ”mantle of the crowd” became much more visible and as a result of that much more vulnerable. There were almost the only ones in the street with the police

The response
The two major institutions: one of substance-free treatment and the other who holds the monopoly of  OST, that dominate with their ideological sometimes perspective, the ‘addiction’ field, stopped at the same time their street work/outreach. The drop-in centres continued their function but with strict measures and also all the substance-free units, gateway to closed communities also stopped to work. The responsibility for the PWUD/PWID in the streets once again shifted from these state-supported and with a budget of millions of institutions to small NGO’s including us.  The last time that happened was back at the HIV outbreak on the IDU’s back at 2011-2013 (I am one of the recorder incidents). It worked actually. Within a very short time, civil society organisations responded to the specific needs of my community. People who were using in the streets at the beginning were bullied from the police but finally, they were left alone. Their needs were not only paraphernalia but also basic necessities of life like food and water. And somebody to talk with…

Our street workers and other service providers transferred to me a clear image of what was going on outside. But after more than three weeks back in my office and after long walks in the centre of Athens I can combine the information they gave me with my own observations.

Indeed there was no change in pricing and the quality of street drugs. At the beginning of the lockdown police tried to dissolve the crowds around the ‘traditional spots’ of drug use in the centre, but not that later it stopped harassing people. Some traditional and long-lasting drug scenes very close to the historical centre vanished not because of the police but because of the dealers who became very visible and that’s why they moved for their own security measures to other spots, near the old commercial centre. Indeed there was a visible increase in the places where the sisa smokers gather and a slight decrease of quality. The same group of people uses heroin (not the injectable type) and benzodiazepines. They were moved slowly from the police without incidents of violence(at least not many)  to the outskirts of the centre. It is probably the first time that this group of people moves from the centre to more remote areas like the central train station. A lot of more let’s say ‘devoted’ heroin users started moving to the west suburbs of Athens where the Roma ghettos are, to find cheap poor quality heroin. Groups of people from Asia carry the staff to the centre and then resell it in double price. But a lot of the Greek origin heroin users moved more or less permanently from the centre to the source of cheap drugs. To the west suburb of Menidi. They can also find cocaine and grass. So we have let say also a  kind of decentralisation of the drug scenes. That was happening of course long before the lockdown but it was really intensified and still is now. That also creates new challenges because it is not an area that the service providers like the street workers who distribute paraphernalia can go there. It is out of the question for numerous serious reasons. Also, the local authorities are not friendly with this kind of activity and the Roma population is extremely hostile. Lot of PWUD that I personally know and I met at my office or talked to on the phone mentioned that due to that, there were numerous cases where PWID shared their works.

What I also observed throughout the cases I dealt with these weeks was the mental and physical deregulation of PWUDs at an increased level not seen before the lockdown. People were very scared, very disorganised, they did not adhere to their antiretroviral medication for HIV like before and most of them were asking for an HIV test because they shared their work. Also, they were not very well informed about COVID 19. Despite the very positive fact of the opening -in at last- during the lockdown of the Shelter for homeless drug users, the more vulnerable of the community is in danger for many many reasons.

I am afraid that we will face all the consequences of all that things in a very short time and as field workers but above all as activists of the most dehumanised and marginalised community of people in Greece, the drug users, we have to be armed with patience and strength to deal with all that and with a new economic recession. What is going on to the societal context directly affects the most vulnerable parts of the population.

When I asked a friend of mine that I know for more than 15 years how things were in the streets during the lockdown he replied “More or less the same. We are junkies and nobody gave a fuck about us. Even the cops did not approach us. …Some days we could not find water or something to eat but thank God we could always find something to score…” He was not the only one who described in a vivid manner the condition like that. That gave me the idea that there was a  small gap between the reality the service providers described to me and the community reality, the actual people who are on the streets. There is always this small gap.  Communities are always let say one step ahead. From service providers, from policymakers, from all sorts of allies and friends. We have always to look to our own analytical tools to decodify the various needs and the pulse of the community.

Marios Atzemis
Harm Reduction Officer, Athens
www.positivevoice.gr

From mid-March to mid-May, Krakow’s Drop-in has been serving its clients, drug users, through a small window in the front door. In this way, they were supported with lunch and hot drinks, needles, syringes and other harm reduction materials.

Through the window information has been given, through the window talks were held and the staff tried to support clients. The window in the door is a remnant of a pharmacy that was here years ago and night duties were carried out through this window. The COVID 19 epidemic brought it back to life.

How do you deal with the epidemic? – Monar asked this question to the visitors of Krakow Drop-in in this extra-ordinary period.

Visit their website here and access to their project documentation.

Since shops and facilities were closed on March 18th, 2020 and the Bavaria-wide going-out restrictions came into effect on March 21st, 2020, the situation of drug users and low-threshold facilities has changed a lot:
Accommodation options such as Drop-Inns only run in emergency operation (no stay possible, only dispensing of consumer utensils, food donations and warm meals continue to run). Consultations were not possible in the first few weeks but now can be organised personally by phone and behind a plexiglass pane.

Staying on the street is only permitted in urgent cases, violations are subject to fines. However, since many only live in pensions and emergency sleeping places, many are still outside and are therefore fined accordingly.

The clinics currently only offer detoxification in emergency cases and no regular admissions are allowed. Most substitution clinics – in spite of the recommendations made by the authorities – have not or only slightly expanded take-home allocation. The reason for this is the low remuneration of the Take Home prescriptions. This has now been changed and it is hoped that Take Home will finally be prescribed by higher numbers.
The feared collapse of the drug market so far has failed to materialize, and all drugs, with the exception of synthetic cannabinoids, are still easy to get on the street. However, a partially massive price increase can be seen.

So far, everyone who wants to be mediated into substitution clinics can be mediated, but so far there is no coordinated concept of emergency substitution because the responsible city authority has been ordered to the Corona programmes. The question will be, how long will the restrictions remain in place? What does the proposed easing bring and how does this affect the drug market?

However, there are a few good things to report. On the one hand, the low-threshold facilities have so far been able to distribute many paraphernalia and the distribution of food donations still works despite the limited offer of the Münchner Tafel. We have received quite a lot of donations so that we can buy groceries and then distribute them to drug users. In the meantime, 80 – 100 clients come to every day fort hat support.

Podcasts on the situation of drug users from 03/26/2020:

Olaf Ostermann,
Condrobs, München

CRESCER develops community-based interventions with a harm reduction approach focused on three vulnerable groups – people who use drugs, people who experience homelessness and asylum seekers and refugees – through a set of services, such as outreach teams, Housing First program, drop-in centre, employment-oriented project, among others. CRESCER’s teams cover the entire Lisbon metropolitan area, accompanying 2000 vulnerable people a year, 1500 of whom are people who use drugs.

On March 18th, 2020, Portugal declared the State of Emergency, beginning on March 19th and ending (until a further decision) on May 2nd. This declaration has imposed a lockdown for the sake of public health, restricting the movement of people in public spaces.

Considering the profile of our clients – vulnerable people who are experiencing or experienced homelessness, most of whom with health conditions, i.e. people COVID-19 high-risk group – and the necessity to continue supporting them, now more than ever, CRESCER has adapted its daily activities. This contingency plan was designed and implemented on March 16th, previously to the State of Emergency declaration, to reduce the risks and take account of possible future constraints in human resources available due to illness/prophylactic isolation.

Since then, outreach teams, Housing First program and the Municipal Programme for the Reception of Refugees in the city of Lisbon have been working daily. Mitigation measures were implemented, such as a team rotation system – teams of two kept working on the field while the other ones were on teleworking, changing every 15 days (in the absence of clinical symptoms) – a decrease of face-to-face interventions and delivery of support through phone/computer-based solutions, and the use of Individual Protection Equipment, in line with the latest Directorate-General for Health (DGS) guidelines. In order to maintain essential services to the community and comply with DGS recommendations, CRESCER has temporarily closed the drop-in centre and its restaurant, an employment-oriented project with on-the-job training for people who experience homelessness.

CRESCER’s activities at COVID-19 time:
– Outreach teams’ daily route on consumption neighborhoods.
– Exchange and distribution of aseptic material to smoked or injected drug use.
– Distribution of soup and alcohol-based hand wipes.
– Social and psychological support by phone.
– Medical and nursing care by phone or on-site in emergency situations.
– Social and health referrals in order to get appointments by phone, ask for medicines and get social support for clients (ex.: financial support, food, products for personal hygiene, etc.).
– Integration of people who experienced chronic homelessness in Lisbon at individual houses with the support of a specialized team.
– Seek individual houses for rent to integrate people who experience chronicle homelessness.
– Seek family houses/bedrooms for rent to integrate refugee families or individuals.
– Home delivery of meals (prepared by Lisbon City Hall services) and medicines with the help of volunteers.
– Support to basic day-to-day tasks (bath, household cleaning, laundry, purchase of goods, etc.) in the most vulnerable cases.
– Distribution of informative flyers on COVID-19, with a simple and direct message about symptoms, routes of transmission, precautions and harm reduction strategies focus on drug use, sexual behaviours, and homelessness situations.
– Restaurant kept closed to the public but opened with a service of cooked meals, prepared by its team of people who experienced homelessness. These peers distribute around 300 meals per night on the street.
– Advocacy about the urgent need to eradicate chronic homelessness and to promote access to housing in order to guarantee the dignity and security of all, through CRESCER’s social networks.

Cristiana Merendeiro
CRESCER

We are here as all across Europe struggling to stay open for our clients; drop-in centres got closed for longer stays so clients only get in if allowed by the local authority or get material over the window, many of them are making reserves- taking 4-6 boxes, actually this week it seems that they started to get out more (due to nice weather) though we don’t have a police hour or similar. My organisation is providing mobile outreach so we need passes to go outside Zagreb. We had to stop for 8 days because we also had an earthquake and aftershocks in Zagreb.

There is a lot of stress in the overall population. Not to mention our clients.
There are problems with finding drugs due to closed borders so we noticed a slight increase in robbing pharmacies.

OST is still being distributed but the max for 2-3 days. Some NGOs suggested we should lobby for 2 weeks (each patient can get OST once per year for 2 weeks for holidays) but this way doctors can actually see them more often- mostly now via windows. Croatia has a unique system of OST distributed by primary care doctors and they are reluctant to have bigger amounts of OST in their practices.

Not to mention that we don’t know when the rest of our funding from Ministry of Health (20% of annual grants) will be paid because all payments from the government side are shut for 3 months at least.
Many local authorities decided not to fund NGOs this year. So our network (5 harm reduction NGOs) made a plan of how to survive, calculating all the commodities we have, if needed we will support each other…

But the biggest concern is trained and skilled outreach workers that will leave us once we don’t have any more funding for their salaries and as mentioned before: all of these made an impact on the general population and their mental health so I am afraid and concerned for our clients.

Centre of Zagreb is ruined, hundreds of buildings so we expect a rise in the number of homeless people (currently they are in student dorms but only until Sept).

So many challenges….and harm reduction is not something that our government is making a priority.

Iva Jovović
Life Quality Improvement Organisation FLIGHT

On 12th March 2020 schools in Ireland closed to help reduce the spread of COVID-19. Five days later, on 17th March, Taoiseach Leo Varadkar addressed the nation stating that ‘Never will so many ask so much of so few,’ referring to the people on the front line of the response to COVID-19 in Ireland. Ten days later, on 27th March at midnight further restrictions designed to reduce the spread of COVID-19 came into place – these restrictions will remain in place until at least 5th May 2020.

Ana Liffey is a ‘Low Threshold – Harm Reduction’ service, working on the streets of Dublin and Limerick, with people with complex and multiple needs i.e. problematic drug use, mental health issues, physical health issues, behavioural issues, etc. The majority of the people we work with are homeless or at risk of homelessness. Our ‘Low Threshold – Harm Reduction’ ethos and the skills & competencies of our team are well suited to helping with the response to a COVID-19 outbreak amongst this cohort of people. Led by the Health Service Executive (Dublin CHO9 & Limerick CHO3), working alongside our colleagues in Homeless and Addiction services, we have had to quickly adapt how we deliver our services to help to reduce the spread of the COVID-19; and to respond to the increased drug-related risks our clients have faced – particularly the increased risk of an overdose. The group of people who use drugs that we work with are a particularly vulnerable group and are at a higher risk of contracting COVID-19. The sharing of syringes, crack pipes, tooters, etc. is risky and increases the chance of infection as COVID-19 is transmitted through droplets. So, providing Harm Reduction interventions is going to continue to be an essential response in stopping the spread of COVID-19 amongst this cohort. Should they contract the COVID-19 there is a likelihood that they will require hospitalisation as many have underlying health issues which put them at greater risk of complications. For example, smoking crack or heroin can cause and/or exacerbate respiratory conditions; or someone with HIV or Hep C may have a weakened immune system.

We quickly recognised that the need to prevent the spread of COVID-19, amongst the people we serve, was now the priority. We recognised that we would have to adapt our frontline services very quickly to prioritise and support the public health response to COVID-19, and our team responded extremely well. We closed our drop-in services and stopped all group work as we could not maintain a safe physical distance for clients and staff. We focussed our efforts on working on outreach in the streets explaining COVID-19, providing our Needle & Syringe Program and explaining how to stay safe on both counts. In the very early days of the COVID-19 crisis, many of the people we met on outreach simply did not know about COVID-19 i.e. no knowledge of the latest advice, what the restrictions were or how the service provision landscape had changed. Our team spent a lot of time explaining the situation, supporting people around their fears & frustrations and getting them linked to treatment and housing options. Soon we found ourselves supporting the medics to assess people we met in the street who had symptoms. We did this over the phone and if they needed to be provided a space in a COVID-19 Isolation Unit, we would arrange the transportation. Working during this period was challenging work for our team as the narrative in the media was of the potential for a steep curve – meaning potentially many infections. However, our team followed the Public Health advice of social distancing, hand washing and other precautions involving the correct use of Personal Protective Equipment in line with Public Health guidelines. We adopted our two vehicles in Dublin by adding Perspex screens between the front and back seats; so, that we could bring people to the new residential Isolation Units provided by the State; and to complete other trips as safe as possible. We are now providing supports to people who are isolating in Dublin and Limerick as needed i.e. bringing whatever they need to them so that they can remain in isolation.

The State’s response of providing accommodation and improved accessibility of prescription drugs (e.g. methadone and benzodiazepines) has helped to stabilise people and helped them to remain in isolation – which helps to reduce the spread of COVID-19. For example, as of 16th April in Dublin City, there had been 20 people within this cohort diagnosed with COVID-19 and no COVID-19 related deaths. Looking to the future, it is not clear exactly what will happen, but concerns we have include…have we done enough to reduce the curve of infection amongst this cohort; what will happen to the drugs market; what impact will the changes to the drugs market have on people who use drugs (whether it be problematic use or non-problematic use); what harms will these risks cause and how can we respond to reduce these harms. It is clear, however, that Harm Reduction has been, and will continue to be, an important part of the Public Health response to drug use during the COVID-19 crisis to help stop the spread of the virus; and to reduce drug-related harm.

Tony Duffin
CEO
Ana Liffey Drug Project

Our operations are compounded by the funding problems of our services that you are already aware of. Our organization is the only one that has survived the provision of HR services in all of Bosnia and Herzegovina.
In accordance with the orders and recommendations of the Crisis Staff managing this health and social crisis, we had to close both Drop-in centres (Zenica and Tuzla), and transferred all forces to the field.

Rapid mapping of the terrain was carried out and interviews with a large number of clients enabled a new methodology of work, all in line with the recommendations on the method of contacts between people. We currently cover all our clients in two regions, covering about 1 million people and about 1800 of our clients, and with the great help of our clients, we have identified in both regions 20 key points – persons to whom we deliver all the materials available to us.

The material is delivered on the basis of the stated needs of our clients and in the period from March 1st to April 10th we distributed in both regions 51 800 needles and syringes, 25 000 pieces of distilled water, alcohol wipes, containers for preparation of the mixture, 1200 containers for disposal of infectious waste.
It should be noted that during this period about 45,000 needles and syringes and other infectious material were collected and deposited in our drop-in centres until this crisis passed.

All of this work is done by 6 of our employees and we all do all the work and have very few resources at our disposal. The biggest win at the moment is the involvement and commitment of our clients throughout this work process. The 6 of us have been volunteering a long time ago and will work as long as we have materials to share with our clients.

If this model of work continues, our supplies are sufficient by the end of June, and after that, we will be forced to close the same after 18 years of conducting HR services in Bosnia and Herzegovina because we will no longer be able to do so.

We are aware that the situation around the world is critical and that priorities have changed, but we also urge you all to appeal to and try to influence donors to support us in the coming period so as not to close the only available services for drug users, sex workers and prisoners in Bosnia and Herzegovina.

Denis Dedajic
President of Association Margina
Bosnia and Herzegovina