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State Policy Center for Opioid Use Disorder Treatment and Access

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Q&A: How Louisiana Has Retooled its Harm Reduction Services for Vulnerable Populations during COVID-19

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As drug overdose deaths accelerate during the COVID-19 pandemic, states are working to ensure that a continuum of services, including access to harm reduction programs, remain available to people with substance use disorder (SUD). The National Academy for State Health Policy (NASHP) recently spoke to Louisiana’s Viral Hepatitis Coordinator Emilia Myers and STD/HIV/Hepatitis Program Deputy Director Anthony James to learn how the state is continuing to provide harm reduction services during the pandemic.

Louisiana authorizes cities, including New Orleans, Baton Rouge, Shreveport, and Alexandria, to operate syringe services programs (SSP). The state has helped maintain these programs by targeting federal grants and through close cooperation between state and community partners.

How have the challenges posed by COVID-19 impacted the day-to day operation of harm reduction services in Louisiana?

Louisiana has six active SSPs across the state. They have stepped up to the challenges of this pandemic and have continued to provide their services, essentially without interruption. They’ve been able to do so through some very innovative approaches, such as hotlines and mail-based naloxone services, and by moving away from brick-and-mortar SSPs. The Louisiana Department of Health (LDH) has worked to improve its relationships with SSPs and link them with their respective local health departments. One result of this manifested in New Orleans where, right when COVID-19 started to ramp up, the city started providing residences for folks who were experiencing homelessness. SSPs went out to the hotels that were housing people to bring harm reduction services to them.

We are also using federal State Opioid Response (SOR) grant dollars in collaboration with the Office of Behavioral Health to fund SSP navigators and federal Opioid Overdose Data to Action (OD2A) dollars in collaboration with the Bureau of Community Preparedness to fund Linkage to Treatment Coordinators (LTCs), who prioritize people who inject drugs (PWID) who have fallen out of hepatitis C treatment. If they are also willing to talk about their drug use, the LTC will conduct a Screening, Brief Intervention and Referral to Treatment (SBIRT). We’ve also been using OD2A funds for our marketing campaign to raise awareness of integrated and co-located care for OUD (opioid use disorder), hepatitis C, HIV, and SSPs to reduce harms associated with substance use disorder, which we hope to continue.    

Luckily, there is buy-in to this work. About a year ago, together with the Office of Behavioral Health and Bureau of Community Preparedness, we developed a state health department-wide, harm-reduction crosswalk, which was an environmental landscape analysis of who’s doing what in infectious disease, who’s doing what in OUD, and how we can create no-wrong-door systems of care. We’ve had some modest gains as a result, including braiding select government funds, scaling up SSP-based OEND (overdose education and naloxone delivery), increasing opt-out hepatitis C testing at select human service district agencies and cross-training OBOT (office-based opioid treatment) providers statewide to deliver both medication-assisted treatment for OUD and treatment for hepatitis C and we are looking to build on our momentum. Our state agencies have innovative leaders that make connections for more effective public health and behavioral health collaboration and care touch points, and we’re fortunate to have trailblazers that keep this work moving along. 

How have people with comorbid HIV and hepatitis C diagnoses been affected by COVID-19, and how has the state responded? 

We know folks who are coinfected are one of the populations most vulnerable to unemployment, poverty, lack of access to health care, and they generally have a lot of competing priorities between trying to take their medications and live their lives. Anecdotally, we are seeing more people accessing SSPs and needing supplies, and SSPs are trying to accommodate that increased demand. With an increase in utilization of SSP services, we hope there will not be an increase in overdoses and or increases in HIV and hepatitis C transmission. I think COVID-19 has really turned access into a challenge and created additional burdens for vulnerable populations, so we have to look at the issue through a health equity lens. There are a lot of systemic challenges and barriers that have been exacerbated by the pandemic, and people’s health has become a lesser priority because they’re trying to survive day to day. 

Within our Hepatitis C Elimination Plan activities [featured in an April 2020 NASHP case study], we have seen decreases in testing and treatment as a result of the pandemic. Before we launched our program, 61 people per month were starting curative treatment. After implementation, we were seeing on average 478 people per month starting treatment. At the start of the COVID-19, that number dropped back down to an average of 155 people per month, but since September 2020, testing and treatment utilization has picked back up. This has forced us to learn how to get testing and treatment outside of brick and mortar treatment facilities, because people are anxious of going into health care systems. Because of funding reductions and other impacts of COVID-19, we revisited our hepatitis C strategy to ensure we were focused on realistic and achievable objectives for the second year of the plan, and reassess what Years 3 through 5 will look like. COVID-19 has forced us to pivot and continuously innovate hepatitis C service delivery. We will use this as an opportunity to leverage our response and facilitate a larger push in harm reduction. 

How does Louisiana’s harm reduction approach support health equity and reduce disparities?

In both the LDH and STD/HIV/Hepatitis Program mission statements, we focus on addressing health equity and racial disparities across the board. Disparities in health care exist and are associated with worse health outcomes, for example the HIV/HCV coinfection diagnosis and prevalence rates are disproportionally higher among Black males primarily in the Baton Rouge and New Orleans areas. Looking at the mono-hepatitis C surveillance data, there hasn’t been a lot of variability in who’s being diagnosed by race. We see disparities in rates of infection by age – we have baby boomers and people who inject drugs getting infected, so we have this bimodal distribution. In an effort to address these disparities in the context of the current hepatitis C/OUD syndemic, we have to pinpoint shortcomings in hepatitis action towards people who actively use drugs and expand primary prevention through harm reduction because treating your way out of a hepatitis C epidemic isn’t feasible. PWID are increasingly researched, but their ability to tell their own stories and provide input into the programs and services they utilize has been historically limited due to stigma. Louisiana is changing that by leveraging community wisdom through community advisory boards to inform evidence-based service delivery. We move this work forward through a core set of values to help us ensure that the services that we and our community partners provide are moving in an equitable direction. 

How has the pandemic necessitated or encouraged new strategies or partnerships?

One of our strategies has been offering provider training. We’ve leveraged Project ECHO to train providers how to leverage telemedicine to treat and manage hepatitis C virtually, revamping remote care. There has been a lot of engagement from clinicians. 

There was also a decline in hepatitis C and HIV testing at the start of COVID-19. Our community-based partners have conducted risk mitigation strategies to safely re-engage people in testing. Now that they’ve been able to get PPE, they are able to conduct testing in community settings again.

We are also prioritizing data sharing and maximizing opportunities to form strong partnerships, because the syndemic of hepatitis C, HIV, and drug overdose is really intertwined, and COVID-19 has only made things more challenging. Reinforcing our partnerships and leveraging data sharing, in addition to amplifying the voices and wisdom of community members, is helping us make these programs work for the people who rely on them.

What would you say are your greatest lessons learned from COVID-19?

We really need to lean into interdisciplinary telemedicine for comprehensive care, especially for the hard-to-reach communities in high-burden regions of the state. COVID-19 has caused so much slow down, but also additional time to re-assess what we’re doing. In this context, developing robust telemedicine programs will be critical. The next challenge will be how to integrate offerings into clinical care beyond the COVID-19 pandemic so that a “one-stop-shop” PWID service bundle will become an increasingly ordinary part of care with movement towards the goal of reducing disparities in infectious diseases and opioid use disorder treatment access.

Harm Reduction in the COVID-19 Era: States Respond with Innovations

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Despite COVID-19 workarounds, such as telehealth and virtual recovery programs enabled by flexible federal guidelines, more than 40 states have reported increases in drug overdoses during the pandemic, underscoring the importance of keeping state harm reduction programs as accessible as possible. 

As COVID-19 upends the nation’s health care systems, treatment for substance use disorder (SUD) has shifted to telehealth environments and recovery programs have gone virtual as state and federal policymakers adjust regulations and guidance to maintain access to services. But the unique risks facing people with SUD during this time of isolation and mandatory social distancing are also becoming more clear.

State-authorized harm reduction programs that provide syringe exchange services, testing for infectious diseases and referral to treatment, and connections to treatment for opioid use disorder and other SUDs provide a critical intervention. Despite the challenges of implementing COVID-19 protocols for what have traditionally been in-person services, states have developed flexibilities and innovative approaches to ensuring that these programs continue to provide critical, ongoing support to people with SUD until they are ready for treatment. 

State guidance for harm reduction providers in response to COVID-19:

The guidance that state officials and agencies have developed recognize the unique challenges that face harm reduction providers during the COVID-19 pandemic. Many states acknowledge harm reduction as an essential service and some have temporarily loosened program restrictions to ensure the continuity of services during the pandemic.

  • The Oregon Health Authority (OHA) authorized its Syringe Service Programs (SSP) to provide curbside services and phone orders for syringes, naloxone, and other supplies. OHA also suggested operational shifts in staffing, distancing protocols, and volunteer management to mitigate COVID-19 transmission among staff, volunteers, and clients. OHA included messaging in support of people who use drugs (PWUD) in order to maintain their safety during the pandemic. The messaging emphasized the increased respiratory risks associated with drug use and COVID-19 and provided guidance on how to reduce the risk of COVID-19 infection as well as the risk of overdose during the pandemic.  
  • In Maine, Gov. Janet Mills issued an Executive Order on March 30, 2020, suspending an existing one-to-one syringe exchange rule, thereby increasing the number of syringes individuals can take home at once. The order also allows flexibility in mail delivery services, needle exchange site locations and operational hours and provided on-site social distancing protocols. 
  • The Missouri Department of Mental Health issued comprehensive COVID-19 guidance in mid-March, which featured published resources from the Substance Abuse and Mental Health Services Administration (SAMHSA), the Harm Reduction Coalition, and the National Health Care for the Homeless Council (NHCHC), as well as best practices from other states and programs. Missouri’s guidance includes operational directives for treatment and harm reduction providers, as well as practical harm reduction guidance for PWUD, particularly individuals who use drugs alone. 

Adaptations in harm reduction services:

Harm reduction programs are making policy shifts to develop practices that respond to the specific needs of their communities. As states and municipalities have responded to the COVID-19 pandemic at varying degrees of restrictiveness, harm reduction programs have also tailored their programs to respond to the pandemic. 

  • Operational changes. Programs in Washington and other states have shifted services outdoors. They now provide curbside or mobile services and have closed their fixed sites entirely and instead rely on delivery services. Many Washington State SSP programs have limited hours and scope of services. In New York, SSPs have been operating with skeletal staff and reduced resources. In response to the new limitations on in-person service, 22 of 23 of New York’s SSPs now rely on some form of peer-delivered syringe services. 
  • Shifts in testing priorities. In addition to continuing to provide harm reduction services, some SSPs in Washington now provide COVID-19 screening and testing at their program sites. West Virginia’s harm reduction programs have reduced the amount of non-COVID-19 infectious disease testing they’re conducting and the amount of hepatitis A and B immunizations they administer, in order to focus on COVID-19 and the immediate needs of individuals with SUD.
  • Emphasizing naloxone distribution. As overdose rates continue to rise during the pandemic, states are increasing access to the overdose-reversal drug naloxone. Pennsylvania’s Secretary of Health signed an updated standing order that allows community organizations to distribute naloxone through mail. Ohio’s Department of Mental Health and Addiction Services has provided official guidance to all community programs through its statewide Project DAWN overdose reversal initiative to maintain minimal contact with individuals who need services while maximizing naloxone distribution as a strategy to mitigate overdoses. Additionally, the US Department of Health and Human Services has published guidance for first responders to safely administer naloxone during the pandemic. 

Looking Ahead

As states begin to consider the impact of COVID-19 on their budgets, programming, and future planning, maintaining harm reduction programs may become more challenging. Harm reduction programs are often supported by multiple funding streams, and program administrators and policymakers may consider leveraging federal grants and other non-state funds to maintain these services. In addition to ensuring access to infectious disease prevention and life-saving treatment and recovery services, harm reduction programs offer a mechanism to maintain engagement with people who have SUD and reduce their risk of overdose, which results from isolation.

This work was funded by the Foundation for Opioid Response Efforts (FORE). The views and conclusions contained in this document are those of the authors and should not be interpreted as representing the official policies or stance, either expressed or implied, of FORE. FORE is authorized to reproduce and distribute reprints for foundation purposes notwithstanding any copyright notation hereon.

Q&A: A Deep Dive into New York’s Drug User Health Hubs with New York’s Allan Clear

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The COVID-19 pandemic poses unique risks to people with opioid use disorder (OUD). Overdose risk increases when using individuals are in isolation and injection drug users are at higher risk of COVID-19 mortality due to increased rates of other infectious diseases and negative health effects from substance use.

State-supported comprehensive harm reduction programs that often provide sterile syringes, naloxone to reverse opioid overdoses, and education and counseling have shown encouraging results and remain critical during the current crisis. As policymakers face tough budget decisions in the coming months, understanding the value of harm reduction services will be increasingly important.

The National Academy of State Health Policy (NASHP) recently spoke to Allan Clear, director of the New York State Department of Health’s AIDS Institute’s Office of Drug User Health to identify the effectiveness of these programs. The institute’s Office of Drug User Health operates the state’s Syringe Exchange Program, Expanded Syringe Access Program, Opioid Overdose Prevention Program, Increasing Access to Buprenorphine Program, and Drug User Health Hubs. Clear has worked with people with substance use disorders (SUD) for decades and ran one of New York’s first syringe exchanges.

Describe the history of harm reduction in New York.

We had been doing underground needle exchange in New York City. The state Department of Health had been monitoring what we were doing and recognized that syringe exchange was of value and important in terms of the HIV epidemic. When the Foundation for AIDS Research said it was going to fund programs in New York City, that’s when the AIDS Institute stepped in, developed regulations, and amended the public health law on syringes, which allowed us to move forward legally and with the blessing of the government.

Learn how states address Co-Occurring hepatitis C, HIV, and SUD:

Read the NASHP report, Tackling the Trifecta: State Approaches to Addressing Co-Occurring Substance Use Disorders, HIV, and Hepatitis C.

Register for the NASHP webinar, Tackling the Trifecta: How States Are Addressing Co-Occurring SUD, HIV, and Hepatitis C, from 2-3 p.m. (ET) Tuesday, May 26, 2020. It features a discussion by state officials about harm reduction during COVID-19.

You don’t see it in documents, but New York state has invested heavily in harm reduction over the years, so our overriding philosophy in the AIDS Institute and Office of Drug User Health is a harm reduction approach.

Why is there an emphasis on people who inject drugs as a distinct service population?

I personally don’t think harm reduction would be necessary if we treated people who use drugs in the way we treat people with ‘medical’ problems. We have a health care system which we call “drug treatment,” which has been developed completely outside of the health care system, which I think is fairly unusual. If you have a pain in your neck or a pain in your stomach, you go to your doctor. If you have a substance use issue, you have to completely navigate an unknown and foreign system to find help. And that help is not in any form of outreach – it’s just waiting for you to find it. And then it’s a very imprecise and inaccurate response to your medical problem. The drug treatment system has never really gotten behind efforts that embrace people who use drugs, as opposed to people who desire to stop using drugs, and people sort of dip in and dip out of the treatment system. And I commend [our] agency for saying, “we do drug user health.”

Describe the inception of the drug user health hub program.

The best health care delivery system for people who use drugs would be the existing health care system. Ideally, we would destigmatize drug use to the extent that it becomes a normal thing for people who use drugs to get a compassionate response and quality health care when they enter the health care system. However, at this moment in time, we don’t have that, so we have to develop a system that exists outside of the mainstream medical system. This is why in New York, we have 24 syringe exchange programs (SEPs), and 12 of them are designated as drug user health hubs.

What is the process for becoming a drug user health hub?

[There is no formal certification process. Selected programs are given additional funding to enhance their regular programming in order to incorporate low-threshold medical care – an approach that offers services without attempting to control a patient’s intake of drugs and provides counselling only if requested.] The office approached a SEP in Albany, that already had a Law Enforcement-Assisted Diversion (LEAD) program, so, they added on extra case management staff to work with the pre-arrest diversion from the Albany police department. The office also approached a SEP in Buffalo, which had been extremely hard hit by overdoses. They used the money to build up capacity to respond to overdoses internally and to conduct outreach and anti-stigma work within the community, as the Buffalo police department was not carrying naloxone at the time. In Ithaca, they did a great deal of work around exploring drug policy reform and decided to do low-threshold buprenorphine program at their SEP. Over time, we’ve added another nine programs.

What are some of the most important services provided by a drug user health hub?

There are also so many restrictions and problems for doctors to prescribe buprenorphine that there’s a big shortage of providers who are willing to do it. We sort of saw buprenorphine as a frontline medication that prevents death from heroin or opioid overdose, and what we have been promoting is that we provide the medication and then find out what the person wants.

[Clear and his colleagues discovered that once people are properly treated and given assistance with resume drafting and interview techniques to help them return to the workforce, they were more amenable to addressing their secondary health needs, including hepatitis C. Describing the individuals that benefit from the services the hubs provide, Clear said, “people would come back and would be interested in other health care – they want other elements of their care addressed. They now have found a venue where they are welcome and where they get the care that they need.”]

How do the efforts of the Office of Drug User Health play into addressing infectious disease?

[Using the opioid overdose reversal drug naloxone as an example, SUD and infectious disease are intertwined.] Naloxone is not really about HIV – it’s obviously about keeping people alive who consume opioids. Back in the late 80s and early 90s, people who inject drugs drove the epidemic here, and now we’re down to something like less than 2 percent a year of new infections among people who inject drugs. The other element in there now that we talk about a lot is invasive infections, so MRSA, staph infections, endocarditis, all of which are on the increase among people who use drugs. We’re doing a lot of work around supporting staff in emergency departments (EDs) to recognize signs of SUD, conduct screening in the ED to see if someone does have an OUD, or if someone shows up with a staph infection to investigate their injection practices.

How would you apply what you’ve seen over the years to the work that needs to be done systemwide?

I’ve been around since the start of the AIDS epidemic and have seen the response and know how to address serious health epidemics for people who use drugs, and here we are – two and a half decades later – still trying to integrate health services …for people who use drugs into a health system that is not receptive to them. It makes me think, “Why didn’t we learn our lesson? Emerging from the AIDS epidemic, why didn’t we make those changes that were sustainable?” I’m hoping that we can, certainly with our office and the relationships we have built with other entities. We should be able to do something that is lasting and transformative.

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