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A Nova Scotia family doctor says we need to have uncomfortable but important conversations around harm reduction initiatives that support homeless populations, especially those in quarantine. 

“Safe supply and this notion of safe supply is still a fairly nuanced practice. There’s a lot of debate, and there should be, because it’s not clearcut and it’s not a willy nilly decision. This is not something that we would want every physician to start doing,” said Dr. Leah Genge.

“This is for clinicians that have a very precise experience with this, and also for a very specific group of people. But even within the addiction community it’s difficult to talk about, to find a national community of practice around this because there’s some varying opinions about that and it’s not necessarily a universally supported practice.”

Genge, a family physician with expertise in addiction who works at Mobile Outreach Street Health (MOSH), Direction 180, and Spryfield Medical Centre, was on hand to help facilitate that harm reduction piece when a number of people were moved from a pop-up shelter into a hotel due to a confirmed case of COVID-19 on April 23. That person was quarantined and everyone else in the shelter (about 35 people) were moved into the Lord Nelson Hotel. 

Genge, along with community groups like MOSH and Mainline Needle Exchange, jumped into action to work on the harm reduction piece. Mainline Needle provided safe needles, while Mental Health and Addictions provided Naloxone kits.

Using British Columbia Centre on Substance Use (BCCSU) guidelines for safer supply, they talked to people about their needs and ensured they had that safe supply to use for the two-week quarantine period. 

“It was something that happened really rapidly. We got news Thursday afternoon (April 23) that we’d gotten the first positive case, and Thursday night I was going through a list of everybody to make sure that everybody’s methadone and stuff was delivered to them and then by Friday we were on the ground trying to sort everybody,” Genge said.

Genge said many people experiencing homelessness also have substance use disorders, and are sometimes using more than one substance. She said her harm reduction visits with those who’d been moved from the shelter happened the very next day.

“This wasn’t in any provincial plan or anything. This is something we just did. We knew it needed to happen. The comments from the staff for me by the time Saturday/Sunday hit were that it was like night and day from the experience of people who were initially put in the hotel room,” she said.

“Nobody knew what drugs they were getting, everybody was withdrawing, everybody was anxious and worried, and worried did they have COVID. And then we went around and the next day everybody was getting delivered their daily supply of what we thought might hold them over. And it was like the chaos had calmed.”

Genge said when it comes to quarantine, asking somebody with a substance use disorder who’s been homeless for months, sometimes years, to confine themselves to a room can be a very anxiety provoking experience. Although they’re grateful for the space, there are significant stresses around things like withdrawal and how to obtain their usual drug supply without breaking quarantine. 

“In speaking to a number of clients during that time and afterward, they were really appreciative to have that consideration for them…You can’t quantify the importance of relationships, but I sure wish you could because having familiar folks around like seeing faces from MOSH, seeing faces from Mainline, seeing the regular pharmacists deliver their methadone and the shelter staff that they’re used to seeing,” she said.

“These are the pieces that are really comforting for people and I think helped me be able to be able to provide harm reduction quickly just by virtue of…being connected to the community organizations that I’m connected to. It already invited a level of trust.”

Genge said once people knew they had a steady 14-day supply, that Genge was on call, and that the MOSH team were also on hand to respond to their harm reduction needs, it “totally took everything down a level” and they got through the two-week quarantine period. 

“But I don’t know that a lot of cities are doing this,” Genge said.

“I’ve posted in several national groups to talk about this, to say this is what we’re doing here, what are others doing and let’s kind of create a community of practice in the same way that BC kind of put out the (BCCSU) guidelines, and I’ve been surprised.”

Genge said while she worries about the people she’s seeing in shelters and those now in hotels and connected to MOSH, those she worries about most are the couch surfers and others under the radar of homelessness who are using drugs and having difficulty accessing their drug supply.

“The illicit market is getting scarier right now. I don’t have any evidence of that from our numbers, but certainly among the people that I serve there have been more anecdotal reports of non-fatal overdoses so I think the illicit drug market is changing here during COVID,” she said.

“And the scuttlebutt around people who use drugs is that it’s definitely a lot harder to get things that people ordinarily would be buying on the street. There’s this hidden population that I worry about and I think to best serve people like that we need to have these conversations.”

In an article published last Friday in the Canadian Medical Association Journal’s online blog, physicians Nanky Rai and Malika Sharma discussed how people who use drugs are experiencing overlapping crises during COVID-19. They also touched on the pandemic’s impact on those who are homeless and use drugs.

“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,” the authors note:

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 health care 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.

Matthew Bonn is a program coordinator with the Canadian Association of People Who Use Drugs (CAPUD), and a National Board member with Canadian Students for Sensible Drug Policy (CSSDP). The Halifax-based advocate is also co-founder of the HaliFIX Overdose Prevention Society which implemented Atlantic Canada’s first overdose prevention site. 

“In Atlantic Canada we still don’t have a lot of overdose prevention sites. We only have one overdose prevention site that is not open right now due to COVID,” Bonn said. “It just makes me so mad that they shut down this as a non-essential service when it’s an essential service. But by the way society looks at harm reduction and people who use drugs, they don’t deem them essential.”

Bonn applauded the harm reduction initiative taken in the hours following the pop-up shelter’s move to a hotel for quarantine. He said ensuring people have access to safe drug supplies during their 14-day isolation period is key.

That was one of my biggest fears when people are getting displaced and going into hotels that are still going to use. I really think it’s about a patient and physician kind of conversation, but it should be implemented and it should be an option,” Bonn said. 

“The response to COVID is going to cause so many harms to people who use drugs, people who are less fortunate, more marginalized. And people aren’t really thinking that far ahead.”

Like Genge, Bonn is concerned about how COVID has changed the local illicit market and is putting more people at risk of overdoses.

“This is getting really bad. And not just in Vancouver and not just in Toronto but here. But my assumption always was that fentanyl has been here, so the supply’s there, but the demand hadn’t quite been there,” he explained. 

“People still want hydromorphs, still want cocaine, crack cocaine, but with the pandemic going on and with shortages being disrupted all over the world…it’s scary. It really worries me.”

He paused before sharing that a good friend had overdosed and died on April 8.

“It still kind of takes me a minute to process, but that’s not the only person that we know, especially in a small place like Nova Scotia. My friend was such an amazing guy that the system really failed, and at the end of it he was struggling with homelessness but he wouldn’t go to a shelter and he was living it rough,” Bonn said.

“And that’s because of the structural oppression for people who use drugs. If he would’ve had a decent hotel room instead of trying to live it rough, he might’ve had a chance to get the proper supports he needed.”

Genge believes one of the lessons we’ll take from COVID is the importance of relationships between vulnerable populations and community organizations in ensuring appropriate responses that best protect those who are marginalized. She also hopes the pandemic shifts the way we think about our connectedness to each other and to our communities.

“People maybe now more than ever are conscious of people who aren’t working right now or have loved ones who have lost jobs and are a few paycheques, or maybe one paycheque, away from really being in financial distress,” Genge said. 

“We could all be one or two steps away from being without a home, and I hope that this experience has taught us that. We’re all deserving of the same things and the same dignity and respect, so I hope we can all talk to our kids in a different way about this and the generation that comes after us will maybe have a more equitable community that they live in.”

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Yvette d'Entremont

Yvette d’Entremont is a bilingual (English/French) journalist and editor, covering the COVID-19 pandemic and health issues. Twitter @ydentremont

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