From New York City to far upstate, New York syringe-exchange providers tell the same story: In March, when the world shut down due to the COVID-19 pandemic, they had to close the drop-in centers that drug users, many of them homeless, relied on daily for clean needles to prevent the spread of HIV and hepatitis C; Narcan, an overdose prevention medicine; HIV and hepatitis C testing; and a warm and welcoming place to use the bathroom, clean up, grab food and coffee, and take part in counseling and support groups.
They say they still don’t fully know the extent of overdoses—some fatal—as well as HIV and hepatitis C infections that might’ve happened in that time.
Since then, those centers have mostly reopened in a way that’s COVID-safe, such as being outdoors under tents, or with appointment-only rather than drop-in visitors. But, say advocates, as they scramble to shore up services in the face of another winter—and a possible second wave of COVID—Gov. Andrew Cuomo is throwing them and the drug users they serve under the bus.
He’s withholding billions in crucial funds to nonprofits including syringe exchanges and refusing to push a tax on the ultrawealthy (such as the one that just passed in neighboring New Jersey) to shore up the state’s COVID financial crisis. His government has withheld scheduled payments to harm-reduction providers—as well as to the nonprofit amfAR, which procures supplies such as clean needles for the whole state. And he’s failing to green-light legislation sitting on his desk to allow overdose prevention centers—sometimes called safe injection sites—that would let drug users inject in a supervised, Narcan-ready setting, out of view of a public that is increasingly agitated by people shooting on the street at a time when available bathrooms, such as in Starbucks, are on COVID lockdown.
“COVID hit while we were already experiencing a nationwide opioid overdose crisis,” as well as trying to reverse rates of HIV and hep C, says Pia Marcus of New York Harm Reduction Educators, which serves injection-drug users in Upper Manhattan and the South Bronx. “Now we could very well be operating in four crises—COVID, overdose, HIV, and hep C. If we want to prevent things, we need to do the above things now. Everyone can say what they want about the cost of doing it now, but if we don’t, it’ll be more expensive later.”
For example, she says, “It’s much cheaper to give people clean needles now than to pay for hep C treatment later.” Such meds costs insurers, private or public, about $80,000 to $90,000 per course of treatment.
A Really Tough Spring
March and April were brutal months for people who live on the streets and use drugs, advocates say.
“When COVID first happened, we had to close our services, with no time to forewarn our clients or for them to gather supplies for the long haul,” such as clean needles and other injection items like cotton balls and alcohol, or kits of Narcan, says Roberto Gonzalez at ACR Health in Syracuse, upstate. “We shut down for close to a month, and upon resuming, we had to make sure all our staff had the PPE in place to be able to both take drop-in visits and do mobile outreach.”
But in July, he says, the agency had to furlough staff and relocate due to a lack of funding. “The payments stopped coming from the state—they were withholding funds without anyone knowing what was going on. We were last paid up in December 2019, so from January to July, we operated without being reimbursed. We went as long as we could before having to let staff go.”
The effect on clients, Gonzalez says, was “mass panic and confusion—it was a huge shift for them. They would try us on a day we were supposed to be open, but we weren’t, and they would just give up. We put out signs, but I guess few people read them. We did our best to put out the word one-on-one [on the streets], and we learned that people were reusing and sharing syringes.”
Thankfully, he says, the agency doubled down on its relationship with area pharmacies, which are allowed in New York State to dispense clean needles to drug users. “We’d have our participants go there and say they were part of our program.”
But, Gonzalez says, while the state has not released official data yet—and likely will not until next year, per usual—he’s certain there’s been an increase in fatal overdoses due to people injecting alone. As COVID has upended informal drug-user social networks and people inject alone, they are unable to administer Narcan to one another.
“Personally, I know seven people who’ve died of overdose,” he says. “And working from home remotely here in central New York, I’d see news reports on ODs. Usually, on a slow day, our Syracuse office alone would give out about 10 Narcan kits, with two doses in each kit, but during COVID, they weren’t going out. When we reopened and people started coming back, so many would cry in front of us because they’d lost someone because they didn’t have Narcan.”
Even their not being able to come to the drop-in center during that time was hard on them, he says. “We’re like an anchor for some people—the only people they connect with that day, week, or month. When people would come in for needles, they wanted to hang around.”
Gonzalez says that, since his agency reopened, “more and more people have been inquiring about HIV and hep C testing, because they believe they put themselves at risk during COVID by sharing or reusing a syringe.”
Arash Diba, director of harm reduction services at VOCAL-NY, which serves Brooklyn, echoed much of this. “More people are using alone, not having their safer spaces where they used before,” he says. The drug supply appears to have been disrupted by COVID, he says, including the appearance that more of it contains deadly fentanyl, which was driving overdose deaths nationwide pre-COVID. All of that means that people may be using larger doses in order to get high—a dangerous act.
Only recently, he says, he and his team had to use an usually large amount of Narcan, including an intramuscular injection (not just the usual nostril shot), to reverse an overdose. “This week alone, we reversed three overdoses and had another three reported to us. Usually, we don’t even have one a week.”
Plus, he says, “We’ve heard stories of people having to reuse dull syringes. I heard someone in the Bronx was sharpening their syringe on a rock.” That, plus using dirty water in the syringe—which some folks apparently did back in March when unable to get bottled water from drop-in centers—leads to an increase in skin wounds and abscesses.
Pressure on Cuomo
On top of all this, police are still stopping and charging drug users with syringe possession even though it is legal in the state, says Melissa Moore, New York director for the Drug Policy Alliance, a national group that advocates for drug-use decriminalization and science-driven harm-reduction measures such as Narcan, needle exchange, and overdose prevention/safe injection sites.
“You can get up to 10 syringes from a pharmacy, but in upstate and western New York, police are still stopping people and asking to see their pharmacy receipts,” she says. “The whole focus should be making sure people have as much of whatever supplies they need to stay safe—not doubling down on criminalization.”
With many advocates, she condemns Gov. Cuomo for having said, at a Sept. 29 press conference in response to reports of increasing visible, public drug use in the city and state, “If someone is openly injecting drugs on a city street, they should be arrested.”
According to Diba, “not doing that” is only the first thing Cuomo must do to stop continued fatal overdoses and new HIV and hep C infections. Foremost among those things, every advocate spoken to for this story said, was to sign legislation allowing agencies to open overdose prevention centers—heated, clean, COVID-safe indoor spaces where people can inject drugs with clean needles, aided by staffers who can help them check their drug supply for fentanyl levels and who can administer Narcan if they overdose. Such places can also be portals to other services, such as mental health and recovery treatment.
As TheBody has previously reported, such sites have operated legally in other countries for decades with a remarkable record of success in preventing overdose deaths, but in recent years, efforts among various cities—including Seattle, San Francisco, Philadelphia, and New York—to open the country’s first such site have fallen apart against public opposition, which has come even from people who complain about open drug use in their own neighborhoods. Additionally, Trump’s Department of Justice has said that it would prosecute any such center in the U.S. if it opened. (One such center, operating underground in an undisclosed city, has been favorably assessed in a study published in the August 2020 issue of The New England Journal of Medicine.)
“I’ll always be the first to say that we need safe injection sites in New York City,” says Mary Brewster, who heads harm-reduction services at the longtime HIV agency Harlem United, which moved its needle exchange to an outside mobile unit when COVID started.
“This issue is not going to go away,” she says. “Drug injection has gone on since people have been able to do it, and it will continue.” She adds that, since COVID started, she has seen people injecting in Harlem’s Marcus Garvey Park several times. “I’ve been here more than three years and never saw that before.” She attributes the uptick to both people avoiding homeless shelters to reduce their COVID risk, and to public bathrooms being closed during COVID.
“We know from both city and state officials that, since COVID, there’s been a huge increase in fatal overdoses in the city, specifically in central Harlem, even if they don’t have the exact numbers yet, so we’ve tried to increase Narcan kit distribution.” She adds that, since her agency started doing hep C tests again a few weeks ago, five of 14 tests have come up positive. “It’s because people have been sharing syringes,” she says.
There is also significant pressure on Cuomo—via a letter from state lawmakers, New York City councilmembers, and nonprofit advocates—to release up to $4 billion in federal coronavirus relief funds to a wide array of nonprofits, including harm-reduction services. (A billion of the total $5.1 billion granted had already been disbursed by mid-September.) But Cuomo has passed the buck to the state budget office, a rep for which said in a Sept. 15 Daily News story on the subject: “The federal government has failed to provide New York and other states impacted by COVID-19 with assistance to offset any of the resulting revenue loss. The state has a $14.5 billion revenue shortfall this year alone, and the funds provided by the federal government can only be used for narrowly defined COVID-related costs.”
Cuomo’s office did not reply to TheBody’s request for comment.
A Similar Picture Nationwide
New York has not been alone in facing new challenges and shortfalls in terms of keeping people who inject drugs alive and healthy in the era of COVID.
Says Lindsay LaSalle, managing director of policy at the national Drug Policy Alliance: “The alarming reports of increased overdoses across the country in the midst of the COVID-19 pandemic are sobering but not surprising. The social isolation required to reduce the risk of coronavirus exacerbates the risk of overdose death. We are living at the intersection of two deadly public-health crises—and without a sufficient harm-reduction infrastructure in most jurisdictions that can offer support and care to our most marginalized citizens, we can only expect that the overdose death toll will continue to rise.”
In West Virginia, which has had the highest rate of overdose deaths in the U.S. the past several years, Laura Jones heads Milan Puskar Health Right in Morgantown, which provides harm reduction services in three counties. Jones says she’s seen about a 20% increase in overdoses since COVID started.
“Most of them are related to fentanyl,” she says, adding that in one Morgantown encampment of homeless folks, most of whom are injection-drug users, there were 14 overdoses in a two-day period. “That’s unheard of. I think the drug supply has changed during COVID, and there seems to be a lot more fentanyl [in drugs such as heroin].”
Thankfully, she says, virtually none of those overdoses were fatal, because they’ve been taking Narcan to the encampment regularly.
“The only fatal one, ironically, was someone who left the camp and got housed,” she says. “The town is trying to destroy the camp, but we’re trying to keep it intact during COVID because [the folks there] have nowhere to go, and we think that as soon as they scatter, we’ll have OD deaths.”
Jones says that it’s too early to say if there’s been a spike in HIV and hep C cases among folks who use injection drugs, “but we haven’t been testing at the same levels that we were. We’re just now getting back to being able to do that.”
In Louisville, Kentucky—another state with high overdose rates—Donald Davis, who heads the Kentucky Harm Reduction Coalition, proudly says that his agency never stopped services, even at the start of COVID. “We were classified as essential workers, and we also worked in areas away from the protests” of the police murder of Breonna Taylor, which has put Louisville on the international radar the past several months.
Despite the agency’s good work, he says that “fatal ODs have increased. We do Narcan, but [during COVID] lots of users were by themselves, and if they’re alone, Narcan is no good,” because somebody else must administer it.
In Philadelphia, a rep for Prevention Point Philadelphia noted that the agency “has found a way to continue most services during COVID and has added more and more with appropriate protocols through the summer and fall. We’ve distributed a ton of Narcan in the last few months, so we think that has helped keep ODs to about the same level as last year.”
However, the rep adds, “those rates were actually on track to decrease this year, pre-COVID.”
And in San Francisco, where open injection-drug use has been ubiquitous for many years now, Phillip Coffin, M.D., who directs substance-use research at the city’s health department, says, “Our overdose numbers have been on their way up anyway the past few years with fentanyl, but we saw a pretty remarkable increase in overdose deaths in May. It’s pretty easily attributable to [COVID-related] social isolation, and we responded with aggressive efforts around expanding Narcan and buprenorphine [a drug to treat opioid addiction] in the [single-room occupancy] hotels [where many people who use drugs live].”
Those efforts, he says, seem to have brought down the May spike.
Where to Go From Here
Winter is coming—meaning not only another possible large, national wave of COVID infections, but increased cold in some parts of the country for people who are homeless who have been living (and, in some cases, using drugs) on the streets. Advocates agree that overdose prevention centers, more low- or no-cost housing with supportive services attached—and more taxes on the wealthy to fund these and other ventures for society’s most vulnerable—are necessary, during COVID and beyond. But they also acknowledge that few of these things will emerge in time for this winter, which leaves them scrambling.
“Everybody has a different plan, which is troubling,” says Pia Marcus of New York Harm Reduction Educators. “All these different programs are trying to figure out what works for them. We’re lucky to have a backyard, so we can move our drop-in center outdoors.” She adds that her organization is also committed to keeping its bathrooms open, as a safe, warm place for clients to inject as well as to clean up. “But we can’t run them without the proper PPE, such as large-size gloves. The state is basically abandoning us.”
Says Brewster at Harlem United: “We need to create a plan of action. We know our clients are going to be going inside again, which is more dangerous because they’re not outside where we can find them.”
She adds, “We know what the solution is. It’s putting pressure on our city government until they allow us to open safe injection sites. It’s not another New York Post article saying that junkies are shooting up in Times Square.”