People who use drugs and Covid19. Protagonists rather than victims

The Covid19 virus is democratic, it doesn’t discriminate. However the pandemic outcomes and conquences are not democratic: they reflect and emphasize current social differences and inequalities. There are social groups and single individuals who pay a higher price in terms of income, poverty, employment, social isolation, health, unequal opportunities in education. The list is long. And this list also includes people who use drugs (PWUD), mostly the more vulnerable ones. It is therefore important and necessary to analyze the impact that the pandemic – and the related policies – has on their lives, and identify and stress all the enviromental, social and policy factors that contribute to this negative impact, in order to implement the most effective countermeasures.

This is the perspective of the major part of research conducted all over Europe during the lockdown, the main goal of which is to protect PWUDs in a two-fold direction: guaranteeing their access to social protection measures expected for the entire population, without discrimination, and guaranteeing their access to drug services (harm reduction, treatment, rehab, social inclusion), that must be considered essential.

This perspective is crucial, of course, and both the rights and the needs of PWUD are important.

But this is not the only perspective we can adopt. Furthermore, it has also some risks, if we don’t clarify the aradigm we use in looking at PWUD behaviours.

The main risk is to focus on PWUD “deficit” (weakness, powerlessness) only or mainly,  and to adopt a victimization approach which, as it turns out, is the “best” premise for encouraging passivity, dis-empowerment, instituzionalization.

Following  the lessons of professor Zinberg

To avoid this risk, and the related victimization threats, it is necessary to start from, and to have clearly in midn, PWUDs competencies, strategies, culture and self-regulation skills. It is a lesson I personally learnt from feminism many years ago: starting from women’s strength, not from their weakness, even if and when they are discriminated, vulnerable or even subject to violence. Being a “victim” as a “role” is not the best premise to obtain respect, dignity or rights.

The need and the right to access a set of services and professional performances doesn’t mean being unable to control, regulate and adapt one’s own drug use, or being powerless in coping with changes. We can look at services and professionals for PWUDS in the same way as for other people: relationship (sometimes useful) that PWUD use in a functional way to control/regain control on their use.  Sometimes services make the difference (and this is why we must guarantee their access), sometimes they don’t, but neverthless the relationship is between a service, a professional and a person who is “expert of his/herself” and has a personal strategy to cope with her/his drug use.

If this is the perspective we adopt, then regarding the pandemic it is also really important to focus on resources and not on deficit: to know how PWUD cope with the current changes, both personal and within the context, looking at them as social actors, as people who can learn from experience, adapt and change their own behaviours in a functional way. People who can control their drug use or, if they loose control for a while, can regain it through their own personal strategies and thanks to the resourses to be found in the context within which they live. In this process, they sometimes need and use professional support, and sometimes don’t.

We must change our way of regarding them, and adopt a drug-set-setting approach, based on Norman Zinberg’s findings and lessons[1]: a) farmacocentrism doesn’t give any exhaustive response. There is no chemical molecule which, by itself, can motivate users’ behaviours. Understanding drug use is based on set (first of all expectations, objectives, meanings and cultures of the use) and on setting (the social environment and the drug use context), and, yes, of course, on drugs. In Zinberg’s perspective, the environmental variables play a crucial role. The social setting is not the same as for the medical paradigm. It is mostly seen as a producer of social norms and rituals (informal social controls) and shared cultures which, though a social learning process, support the controlled use of drugs; this works both for legal drugs (the well known alcohol drinking social model, or Mediterranean model) and for illegal drugs. b) the use trajectories are not linear – as the medical / addiction model wrongly asserts (from recreational use to addiction, or the so-called “all or nothing” theorem, or abstinent or addicted)– but are variable, oscillating, with peaks of more intensive use which alternate with more moderate use periods or temporary abstinence. In general, the lifelong trend is towards a more moderate use. c) every user has her/his own personal strategy to keep the use controlled or regain it after a peak, and the great majority of users regain control without professional support (self recovery). d) the user is always a user-in-a-context, and the context makes the difference with regards to both self-efficacy and capacities/competencies [2].

The “surprising case” of Italian users

During the first lockdown and in the following months in Italy, drug professionals were surprised and often incredulous: their clients got Covid19 much less than the general population; ovedose numbers did not increase; they did continue to use drugs but in a more moderate way and they did ask for information on Covid and for prevention tools. All that notwithstanding the fact that their health was often not at its best.

Suprise and bewilderment! Some months later, a study by one of the Italian scientific societies on drugs and drug addiction, based on data from thousands of Public drug units’ clients, provided an evidence- based confirmation to those common impressions: their clients were infected seven times less than the general population[3].

In the meantime, someone [4] thought that, mostly in the case of heroin users, there could be some physiological, organic reason for this- something to do with inflammatory processes in PWUD. Anything rather than accept the idea of PWUD resilience, coping and adapting capacities, functional changes and risks limitation skills dealing both with the pandemic (like many other people) and the drug use.

While Italian neo-biodeterminism took its course, an NGOs network promoted four researches on the changes in drug use patterns and PWUD’s strategies during the first lockdown (March-May 2020). Out of these researches, three were quantitative, conducted through on-line questionnaires and one was qualitative, through in-depth interviews[5]. The researches regard different populations: recreational users not in contact with any services, except for outreach/netreach interventions for risks limitation; marginalized people often living and using drugs in the streets, in contact with Harm Reduction and treatment services; people who use drugs in different, mixed contexts. Each one of these studies focused on changes in PWUD patterns of use, according to the drug-set-setting perspective, as well as other variables dealing with life during the lockdown: personal coping strategies, psychological and emotional conditions, the relationship with drug services, feelings about the future. Each one obtained its own specific results, based on the differences among the participants.

The relative homogeneity of the research objectives and variables has however allowed for a second, transversal level of interpretation of the four studies

I have conducted – in continuous dialogue with the other researchers – this second level reading of the most relevant findings[6], according to Zinberg’s perspective, one that I had already adopted in previous studies[7]. I looked at changes, functional adaptations and personal strategies PWUDs adopted to keep control of their drug use and cope with the pandemic challenges without increasing drug related risks and harm.

While considering differences and specificities among the researches, some findings have commonality with regard to the prevalent responses:

• PWUDs adopted responsible behaviour with regard to Covid prevention and did respect the lockdown rules. They asked services for information on Covid and for PPE , being in tune with the general Italian population
• During the lockdown they often had to (come back to) live with the family of origin. In these cases they often took care of parents or others and contributed to keeping the house.They ensured that their use of drugs did not have a conflictual or negative impact on family relationships, through more cautious behaviours
• Like all, they had moments of anxiety, solitude, boredom and sometimes depression. They chose drugs that were more functional in order to cope with these feelings, giving up on stimulants, using more cannabis (more than psychotropic drugs). In general they did not use these drugs in an intensive or uncontrolled way. It is important to stress that on average there has not been any relevant increase, despite that difficult emotions during the lockdown could have justified this, from a self-care perspective
• PWUD adapted to the changed setting in a functional way. Mostly when the usual setting of use was social and collective, they abandoned or strongly reduced stimulants and other party setting drugs, due to the lack of reasons and objectives for this use
• They tried to keep to the use of drugs they already knew, avoided or limited shifiting towards other substances; did not experiment new drugs (even if available on the market) not to risk, being in a family context or living alone, and not to risk needing help in a such difficult situation, understanding the limited access to first aid and emergency services during this period.
• They tried to keep the same pusher, to limit variations in the quality of the drugs. About six users out of ten did suceed, even if with some difficulties and higher prices. In Italy the drug market never closed, except for some restrictions for a couple of weeks at the beginning of March.
• They rarely used the web market, and when they did, it was the internet mostly, not the crypto markets
• Their use of drugs on average decreased; variations in drugs availabilty are not the principle reason (in Italy illegal drug supply never stopped- the market was really resilient). The most relevant reasons were: changes in the settings and the lack of advantages in using social drugs in the lockdown setting; avoiding using while feeling too negative; to avoid conflicts with family of origin, partners or children; to respect the drug expenditure limits, considering both higher prices and diminished income.
• the use of alcohol also decreased, but mostly for those who used it in a recreational, social and occasional way. In these cases there is a similarity with use/non-use of stimulants. On the contrary it increased for habitual and daily users. For both groups however, there is a significant decrease of binge drinking episodes, if compared with the previous period.
• users adopted some self-regulation rules in using drugs during the lockdown, to keep control of frequency and dosage: i.e. they decided to use only at certain times; organized daily life in a structured way (study or work, housework, cooking, going out etc) to have some “social tasks” to respect despite the lockdown; respected some rules dictated by the cohabitation with others.
• they respected the usual measures of prevention and harm and risks limitation, continuing to use sterile materials (in this regard, the access to Harm Reduction services have been important for their personal strategies)
• those in treatment with a drug service tried to maintain the contact, also on line
• the majority of those with a prolonged Take Home Methadone program said that had no difficulty in managing it (OST Units confirm this positive outcome)

Conclusions

I really believe that studying what happens during the Covid19 pandemic is useful not only to understand what happens to PWUD in an “exatraordinary” moment, but mostly to better understand, through an emergency situation, what happens “in the ordinary”. In this perspective, this transversal reading of the four researches tell us a lot.

First of all, that the breathless, unthinking and compulsive need of a drug whatever it is, that belongs to the mainstreaming representation of drug users, is not real for the greater part of them, not even in such a difficult moment. Once again the research negates the sterotype of a drug user who is always, by default, unaware, unable, uncontrolled. During the lockdown PWUD had significant control over their use of drugs, adopted coping strategies, adapted to changing living conditions and drug using settings and minimized risks.

Secondly, all of this definitively obliges us look at PWUD as social actors who are able to learn from experience and to change their own behaviours in a way that is functional to their objectives. The concept of “functional use” of drugs – which includes harm and risks limitation, but is not limited to this – is a “compass” to also ri-orient the approach and goals of Harm Reduction policy and interventions, toward a proactive aproach, more than to a preventive approach: the perspective is safer use, based on the advantages of the use and on the minimization of the disadvantages, according to the user’s priorities; based on the empowerment of the users and of the environmental resources[8].

Third, farmacocentrism. The overwhelming dominance of drugs over set and setting dimensions is contradicted by users biographies and by the research that reveals them.

To conclude, the pandemic has an impact on PWUD, causes difficulties and exposes them to risks. But it also reveals that they are much more protagonists than victims.

We have to learn the lesson: individual self-regulation and what Zinberg calls social norms and rituals (informal social controls) can be the basis for a different, social government of the drug phenomenon in contemporary times. This regards also services and professional interventions which should aim at recognizing, supporting and enhancing what users know about themselves and are able to do for themselves.

Notes

[1]Zinberg N. (1984) Drug set and setting. The basis for controlled intoxicant use,  Yale University Press

[2]There is a wide scientific literature and evidence based studies supporting these findings; in Europe, among others, by Peter Cohen, Tom Decorte, Jean Paul Grund. See a bibliography (in EN) by Forum Droghe -NADPI Project,  From Diseased to In-Control? Towards an Ecological Model of Self-Regulation & Community-Based Control in the Use of Psychoactive Drugs, http://formazione.fuoriluogo.it/wp-content/uploads/2014/01/NADPI-scientific-repertoire.pdf

[3]SITD, Covid e tossicodipendenza, http://www.quotidianosanita.it/studi-e-analisi/articolo.php?articolo_id=89539

[4]Massimo Barra, Italian Red Cross, https://www.ilmessaggero.it/italia/tossicodipendenti_contagio_coronavirus_immuni_drogati-5207800.html

[5] The researches: Lockdown e uso di sostanze. Una ricerca esplorativa, Neutravel with the collaboration of Forum Droghe, CNCA, Itardd, Kosmicare (PT), EnergyControl (E) [274 respondents]; Drugs&Covid, CNCA-Gruppo RdD, Forum Droghe, Itardd [288 respondents]; #Telodicoio, ItanPUD with the collaboration of Forum Droghe, Itardd, Harm Reduction International (HRI) [115 respondents]; I consumi al tempo di COVID19. Una ricerca qualitativa,  Forum Droghe, CNCA, Itardd (report by December) [40 in-depth interviews]

Researches reports (in IT) can be read here: https://www.fuoriluogo.it/ricerca/lockdown-e-uso-di-sostanze/#.X7AjUshKjIU; https://www.fuoriluogo.it/mappamondo/perche-nulla-torni-come-prima/#.X7Ajq8hKjIU

[6]Ronconi S. e Di Pino G. (2020), Strategie del consumo in tempi di Covid19, in XI Libro Bianco sulle droghe 2020, https://www.fuoriluogo.it/pubblicazioni/libro-bianco-sulle-droghe/droghe-e-coronavirus/strategie-del-consumo-in-tempi-di-covid-19/#.X7Aqo8hKjIU ; Ronconi S. (2020), Consumi e servizi. Ci sono lezioni apprese dalla pandemia?, in MDD-Medicina delle dipendenze, n.39/2020,

[7]Ronconi S. (2010) Non solo molecole. Evidenze biografiche e stereotipi chimici, in Zuffa G, Cocaina. Il consumo controllato, EGA;  Ronconi S, Zuffa G (2015) Cocaine and stimulants, the challenge of self-regulation in a harm reduction perspective,  Biostatistics and Public Health 12(1) – Suppl. 1. ; Ronconi S. (2018) Trajectories and self regulation strategies of people who use cannabis. Report from national studies in Belgium, Italy and Spain (in EN) [NAHRPP- New Approaches in Harm Reduction Policies and Practices Project; National reports by Antonella Camposeragna (Forum Droghe, Italy); Ruben Kramer (Ghent University, Belgium), Oscar Pares (ICEERS, Spain )]

[8]With regard to a proactive approach in Harm Reduction see:  Grund JP, Ronconi S, Zuffa G, (2014)“Beyond the disease model, new perspectives in HR: towards a self regulation and control model” (NADPI Project), http://formazione.fuoriluogo.it/wp-content/uploads/2014/01/NADPI-ws1-operational-guidelines-fv.pdf ; Forum Droghe-NAHRPP Project (2018)   Recommendations towards a new approach for cannabis consumption models and for an efficient alternative policy ,  https://www.fuoriluogo.it/ricerca/nahrpp-nuovi-approcci-riduzione-del-danno/#.X7PeqWhKjIU

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