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Editor’s Note: This article was published on December 30, 2020, at NEJM.org.
Points of View
Persons with substance use disorders (SUD) in the United States have been disproportionately affected by the Covid-19 pandemic — not only are they, like patients with other chronic diseases such as diabetes, at increased risk for severe disease and death due to Covid,1 but data show that overdose deaths have increased during the pandemic.2 Furthermore, there is significant overlap between populations with SUD and those facing housing instability and homelessness, domestic and sexual violence, and incarceration — social conditions that increase Covid risk.3 To date, only persons who use tobacco, not substances such as opioids, are being prioritized for early vaccination.4 Given the data, however, I believe it’s imperative not only that persons with SUD — particularly those in living conditions that increase Covid risk — be prioritized to receive the vaccine, but also that rollout plans account for specific barriers to uptake in this population.
To develop effective strategies, health professionals must first contend with this population’s mistrust of us. Addiction remains a disease for which people are routinely denied appropriate care on the basis of providers’ beliefs. The medical profession has often fueled the fire of stigma, driving people away and cementing distrust. Unfortunately, many people with SUD have turned to illegitimate information sources and have fallen prey to conspiracy theories. It is, therefore, naive to believe that people with SUD will unquestioningly and willingly line up for vaccinations.
Second, persons with SUD will encounter structural barriers to vaccination, including inadequate access to transportation and technology, which limit their ability to reach vaccine administration sites and make tracking patients and administering second doses difficult; and unstable housing and food insecurity, which underscore the problem of the competing priorities of higher-order needs.
How, then, should vaccination programs be developed for people who use drugs (or are in recovery) to facilitate vaccine uptake?
First, trust-building campaigns and dissemination of accurate information are paramount. Health professionals should be accessible to the community to answer questions and improve relations, which can be done, for example, by holding listening sessions at local shelters, SUD treatment or detox centers, or syringe services programs to hear about the fears and needs of the population. But building trust takes time. Trusted people such as peer navigators, recovery coaches, and harm-reduction service providers could be asked to serve as vaccine ambassadors.
Second, vaccination programs should go where people are and investments should be made in removing structural barriers. Health departments should plan for vaccine administration at sites such as methadone clinics, syringe services programs, and Alcoholics Anonymous and Narcotics Anonymous meetings. Administration of other vaccines at syringe programs has been highly successful,5,6 and providing vaccination at places where trusting relationships exist and where people regularly obtain care will make it easier for people to receive both doses of vaccine.
Local and state governments should consider providing resources and services including hotel accommodations, food or food vouchers, and telephones and chargers, as well as the services of case managers and social workers at vaccination sites. Such services would increase the likelihood of completion of the vaccine series and would improve long-term outcomes, including sustained recovery, overdose reduction, and housing status.
Finally, the roots of mistrust are deep, and vaccines will probably need to be administered by trusted professionals. I believe those who already serve people with SUD — such as outreach workers and peer navigators — should be classified as essential workers and be prioritized for the vaccine. They are vital to the success of vaccination programs.
Some people will argue that such extraordinary measures should not be taken for this population. These arguments, though, are rooted in the same stigma that caused such mistrust in the first place. Officials devising vaccination strategies and allocation plans would be wise to do so from the perspective of the virus, rather than that of stigmatizing personal beliefs.
Joshua A. Barocas, M.D.
Boston Medical Center, Boston, MA
Disclosure forms provided by the author are available at NEJM.org.
This article was published on December 30, 2020, at NEJM.org.
1. Wang QQ, Kaelber DC, Xu R, Volkow ND. COVID-19 risk and outcomes in patients with substance use disorders: analyses from electronic health records in the United States. Mol Psychiatry 2020 September 14 (Epub ahead of print).
2. Friedman J, Beletsky L, Schriger DL. Overdose-related cardiac arrests observed by emergency medical services during the US COVID-19 epidemic. JAMA Psychiatry 2020 December 3 (Epub ahead of print).
3. Vasylyeva TI, Smyrnov P, Strathdee S, Friedman SR. Challenges posed by COVID-19 to people who inject drugs and lessons from other outbreaks. J Int AIDS Soc 2020;23(7):e25583–e25583.
4. Centers for Disease Control and Prevention. How CDC is making COVID-19 vaccine recommendations. December 2020 (https://www.cdc.gov/coronavirus/2019-ncov/vaccines/recommendations-process.html#groups-considered).
5. Des Jarlais DC, Fisher DG, Newman JC, et al. Providing hepatitis B vaccination to injection drug users: referral to health clinics vs on-site vaccination at a syringe exchange program. Am J Public Health 2001;91:1791–1792.
6. Stancliff S, Salomon N, Perlman DC, Russell PC. Provision of influenza and pneumococcal vaccines to injection drug users at a syringe exchange. J Subst Abuse Treat 2000;18:263–265.
January 14, 2021
N Engl J Med 2021; 384:e6
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