For over a year, communities have felt the ongoing global impacts of the COVID-19 pandemic on our health and wellbeing (physically, mentally, and emotionally). Socially, we have weathered lockdowns and social distancing, job loss, and disappointing, undelivered vaccine rollouts. We have collectively experienced the uncertainty concerning a return to normalcy, and our desire for that return to take place in the near future. However, for our unhoused drug using community members, the impacts of the COVID-19 pandemic have been exacerbated, and are compounded by North America’s drug poisoning Emergency.
In an effort to minimize COVID-19 risks, there have been increased actions nationwide to provide temporary housing to people experiencing homelessness. Efforts span from temporary hotel stays to sanctioned and clandestine encampments. Attention has been drawn to the disproportionately felt consequences that COVID-19 has had on unhoused populations. While housing efforts are critical, many shelters, hotels, and temporary housing initiatives have maintained punitive policies around drug use, increasing risk and harm for those staying there; as it forces people to hide their use, endangering their lives, completely contradicting harm reduction principles.
These environments are increasingly problematic as fatal overdose rates continue to rise during the pandemic, with the United States having experienced a 29% increase in overdose deaths from September 2019 to September 2020. Many jurisdictions are projected to experience the worst overdose death rates to date. Despite these increases, harm reduction approaches are glaringly missing from many shelter-based and temporary housing programs.
In Rhode Island, a state that has continued to experience significant rates of overdose, the COVID-19 pandemic has led to sharp spikes in fatal overdoses. From 2019 to 2020, Rhode Island experienced a 25% increase in fatal overdoses. At 384 overdose deaths, it’s the highest number on record in the state. Although this trend has gained widespread attention statewide, it has yet to significantly impact how temporary housing is developed, operated, and implemented during the pandemic.
Amid the first wave of the COVID-19 pandemic, Rhode Island helped fund COVID-19 hotel-shelter programs. This initiative not only provided a space for unhoused folks to isolate after a COVID-19 diagnosis or exposure but also aimed to relocate shelter residents to minimize transmission within communities. This program was refunded in the beginning of 2021 in the midst of Rhode Island’s second wave. The housing initiative has since led to over 150 rooms being secured for over 200 people. While this has been helpful at reducing the number of shelter occupants and supporting the relocation of unhoused community members, these services lack a comprehensive harm reduction approach.
“When we fail to practice the Housing First model in all capacities, including shelters, we fail an entire vulnerable population.” – Rhode Island peer outreach workerHousing First has been positioned as a key approach to providing housing for people who use alcohol and other drugs. These models aim to provide permanent, supportive housing to individuals experiencing homelessness, without requiring abstinence or engagement in treatment. While entry requirements may allow people who use drugs to stay there, Housing First can fall short of truly supporting individuals if they do not incorporate harm reduction policies, principles, and procedures.
‘Don’t use alone.’ ‘Go slow.’ ‘Test your drugs before using.’
The former is universal harm reduction messaging, but what happens if you’re staying in a shelter or other temporary housing with anti-use policies, where on-site drug use warrants leaving? How do you choose between autonomy and shelter? In Rhode Island, this is the predicament many people who use drugs face when they are temporarily housed in shelters or COVID-19 hotels. Although operating under a Housing First model, shelters and temporary hotels do not incorporate harm reduction approaches. Rules prohibiting guests in rooms, random wellness checks, and getting kicked out if staff find evidence or stories of use all exacerbate fatal overdose risk. The consequence includes people being forced to make the choice between wellness and shelter.
In a recent meeting with an outreach worker, she told the UPHNS Hub about these challenges and what it means for her clients: “I’ve had folks I’ve been working with get kicked out of shelters for using, and subsequently dying from and overdose, fatal overdose while using alone in a grant funded hotel, rejecting clean needles and Narcan out of fear that they will get kicked out of their hotel program, and so on and so forth.” they continued sharing their experience “All of this could have been avoided if we provided a harm reduction-based environment to these individuals. Overdoses are the highest they’ve been, and everyone should be doing everything they possibly can to prevent fatalities from happening.”
These issues are compounded by the fact that many services in the state are often siloed, leading to gaps in integrating harm reduction programming. While this is partially due to agencies being overworked and often on shoestring budgets, there are also philosophical differences that can undermine overdose prevention efforts in the state.
“We have to go back to the days when Housing First started in New York, and was adopted in Vancouver and London. Where it was a Harm Reduction approach, so individuals could be housed and did not need to go to treatment, or follow a narrow view of recovery.”
We have to go back to the days when Housing First started in New York, and was adopted in Vancouver and London. Where it was a Harm Reduction approach, so individuals could be housed and did not need to go to treatment, or follow a narrow view of recovery. While low-barrier admission criteria to housing is imperative, it doesn’t really matter unless we help keep people with shelter. A necessary first step is eradicating punitive policies that require using in harmful ways that can increase someone’s risk of a fatal overdose or other drug policy related harms. We also have to alter our perception of recovery away from abstinence, and instead, provide individuals with a range of supports that meet their needs. There is also an urgent need to implement harm reduction services like naloxone, and drug purity testing technologies into shelters, hotels, and other non-profit housing.
“Integrating harm reduction approaches into Housing First works, and is critical to meaningfully support residents who use drugs.”
Integrating harm reduction approaches into Housing First works, and is critical to meaningfully support residents who use drugs. Too many people have died for housing providers to not shift their philosophy to include harm reduction. We need harm reduction in shelters and hotels, and we needed it yesterday. The time to act is now!
Dr. Alex Collins
is a postdoctoral research associate in the School of Public Health and Brown University. She is an ethnographer and qualitative research focusing on housing, overdose, and access to harm reduction services. Since returning to the US after living in Vancouver for six years, her goal is to contribute towards the implementation of evidence-based harm reduction interventions in the US.