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Content uploaded by Artur Malczewski
Author content
All content in this area was uploaded by Artur Malczewski on May 20, 2020
Content may be subject to copyright.
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The impact of the COVID-19 epidemic on drug services,
drug users and drug market in Poland
– findings of the rapid situation assessment
Artur Malczewski, Michał Kidawa, Maria Bevz
Reitox National Focal Point
National Bureau for Drug Prevention Poland
18 May 2020, Warsaw
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Table of contents
1. AIMS OF THE STUDY ............................................................................................................................... 3
2. METHODOLOGY ................................................................................................................................... 3
3. LIMITATION OF THE STUDY ............................................................................................................... 4
4. WHO TAKE PART IN THE SURVEY?..................................................................................................... 4
5. DEMAND FOR DRUG TREATMENT AND HARM REDUCTION ............................................................. 5
6. AVAILABILITY AND PROVISION OF DRUG TREATMENT AND HARM REDUCTION SERVICES .......... 8
7. OPIOID SUBSTITUTION TREATMENT............................................................................................... 12
8. OBSTACLES AND CHALLENGES ......................................................................................................... 13
9. DRUG USERS AND DRUG MARKET .................................................................................................... 15
10. SUMMARY AND CONCLUSIONS ....................................................................................................... 16
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1. Aims of the study
The COVID-19 epidemic has considerably affected the services of the healthcare and
aid services in Poland. Needless to say, drug services have not been spared. In order
to make a rapid assessment of the situation and its impact on drug users and the
clients of drug services, the Polish Reitox Focal Point – National Bureau for Drug
Prevention (NBDP) (Polish name: Centrum Informacji o Narkotykach i Narkomanii
Krajowego Biura ds. Przeciwdziałania Narkomanii) conducted a survey mainly among
drug treatment units and harm reduction programmes. The assessment was aimed at:
• examining the operations of drug services during the coronavirus epidemic.
• identify innovative responses in this area.
• intended to determine the challenges that the aid system is currently facing.
• describe the situation of the drug users
• describe changes on the drug market in terms of the availability of psychoactive
substances.
2. Methodology
The research tool was developed by the EMCDDA and with certain modification, it
was applied by the Polish Reitox Focal Point NBDP in the nationwide survey. In April,
the Polish Reitox Focal Point NBDP distributed the survey questionnaire among drug
services in Poland. The questionnaire was also sent to Provincial Drug Information
Experts, who subsequently forwarded the questionnaires in the provinces of lodzkie,
swietokrzyskie and dolnoslaskie. In addition, the questionnaire was posted on the
website of the Polish Reitox Focal Point (https://cinn.gov.pl/portal?id=1630635). The
survey was conducted between 14 April and 6 May. Seventy-One (71) institutions
responded to the survey in this time. Moreover in aim the clarify information from the
questionnaire we made a few phone call to persons who had filled out the
questionnaires. Quantitative data from the survey is presenting in the form of charts.
In the case of open questions, the most important conclusions from the analysis of
these questions were presented in the report, which quotes the survey responses in
italics. The questionnaire had a modular structure, which is why most institutions
completed part of the questionnaire. The number of surveys used to present data on
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the chart was given with "N". The result of the study were presented on two internal
presentation for staff of National Bureau for Drug Prevention and discussed.
3. Limitation of the study
It is worth mentioning that the questionnaire was sent to two hundred (200) institutions
what means that we got the pictures of the situation from the part of the institutions.
The situation is also changing fast and hopefully in June we will see improvement in
the access to drug treatment and harm reduction. However, a worst case scenario of
a further decline in drug services availability cannot be excluded. The report includes
the information about the situation in the drug service at the beginning of the COVID-
19 epidemic (March and April), when the situation was the most difficult for the aid
system due to "lockdown" and introduction of sanitary regulations.
4. Who take part in the survey?
Table 1. shows data on types of institutions which took part in the survey. A single
survey questionnaire could be completed by two different institutions e.g. a drug
counselling centre and a harm reduction programme as the questionnaire had a
modular structure. The questions related to the following areas: drug treatment, harm
reduction, opioid substitution treatment and drug market. Depending on the type of
services, an institution completed a dedicated module. The survey was targeted
mainly on treatment services and harm reduction programmes therefore most of the
returned questionnaires were completed by drug treatment units (82%) and in less
extent by harm reduction programs. One questionnaire was completed by the
Provincial Police Department.
Table 1. Types of institutions that participated in the survey
Drug treatment unit
81.7%
Non-governmental organization
21.1%
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Drug enforcement service (e.g. Police)
1.4%
Harm reduction programme
12.7%
Prevention institution
7.0%
Other e.g. Provincial Drug Information Expert
12.7%
5. Demand for drug treatment and harm reduction
One of the fundamental questions asked in the survey concerned the demand for drug
treatment services. We asked the respondents whether they had noticed any changes
in this area since the containment measures in response to the coronavirus epidemic
in Poland were introduced. 69% of the respondents reported that there had been a
decrease in the number of drug treatment entrants while 10% reported an increase
(Figure 1). The highest percentage of the respondents considered the decrease in the
demand for drug treatment to have been significant. The survey results show that as
a consequence of the epidemic fewer drug users sought treatment. One of the major
barriers was probably the limitation of drug treatment service as well as the closure of
some facilities: “In accordance with the recommendations of the National Health Fund
the operations of the Drug Therapy Day Care Centre have been suspended”.
Figure 1. Have there been overall changes in seeking drug treatment services
since COVID-19 containment measures were introduced in your country? (%)
(N=68)
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According to the data gathered in the course of the survey, drug treatment services as
well as the majority of harm reduction programmes have seen a decrease in the
number of patients. The decrease refers mainly to new entrants. Some facilities,
especially residential and day care centres, in the first weeks of the epidemic refused
to admit new patients. One of the major obstacles to the admission of new patients
were the limitations on new entrants. Methadone substitution programmes started to
dispense methadone for longer periods (e.g. 14 days). From the vantage point of the
patient, already covered by the drug services, the group who suffered most from the
new situation was group therapy patients. Drug counselling centres suspended on-
site group therapy sessions and moved online. Here is a comment made by a drug
treatment unit: “The decline in service provisions mainly refers to new patients. In the
first weeks of the epidemic we did not admit new patients for treatment. Most of the
patients already in therapy on the day of the introduction of the state of epidemiological
threat are still being provided with healthcare services. The most significant fall has
been observed in the group therapy patients. 50% of such patients are taking part in
the sessions conducted via online platforms”.
The survey also sought to check whether the decrease in new patients had also
occurred in harm reduction programmes (Figure 2). In this case, a large proportion of
the answers said “No change” (38%). However, over half of the harm reduction
facilities which had participated in the survey reported a decrease in the demand for
harm reduction (51%): “Harm reduction clients in our programme are considerably
42.6
26.5
20.6
7.4
2.9
0.0
5.0
10.0
15.0
20.0
25.0
30.0
35.0
40.0
45.0
Strong decrease Slight decrease No change Slight increase Strong increase
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lower by approximately 20-30%. The most significant fall is noticeable in the group of
clients who are fairly stable in terms of the housing situation. Homeless individuals are
benefiting from our limited offer more frequently than the other clients.”
Similarly, to the situation in drug treatment units, 11% of harm reduction programmes
had recorded an increase in the number of clients.
Figure 2. Have there been overall changes in seeking harm reduction services
since COVID-19 containment measures were introduced in your country? (%)
(N=37)
A dramatic change as a result of the epidemic was observed in harm reduction
programmes whose operations were performed in streets or clubs (nightlife settings
programs). The new epidemic-related regulations considerably limited access to most
venues or even shut them down. Harm reduction programmes faced the following
obstacles to their operations as a result of the epidemic:
• Ban on gatherings, which makes it hard to work with the clients
• Neighbours’ concerns and objections to drop-in centres. Suspicions of harm
reduction programme clients being infected with the coronavirus.
32.4
18.9
37.8
8.1
2.7
0.0
5.0
10.0
15.0
20.0
25.0
30.0
35.0
40.0
Strong decrease Slight decrease No change Slight increase Strong increase
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• Closure of night clubs – no option of on-site outreach work
• The Police do not recognize street outreach workers and officially bans
contact with more than one individual.
6. Availability and provision of drug treatment and harm reduction services
Another area of the survey was the question of the availability of drug treatment and
harm reduction during the epidemic. Are these services still open to the public or have
they reduced their operations? According to 86% of the survey respondent there had
been a decrease in the availability of drug treatment. Only 2% of the respondents
reported a slight increase (Figure 3). A decrease was also observed in the availability
of harm reduction programmes (77%) while an increase was noted by a mere 3% of
the respondents (Figure 4).
Figure 3. Have there been overall changes in the availability and provision of
treatment services in your country since COVID-19 containment measures were
introduced? (%) (N=62)
According to the survey, counselling over the Internet is the main method of providing
medical service in outpatient clinics. However, the introduction of new work methods
48.4
37.1
12.9
1.6 0.0
0.0
10.0
20.0
30.0
40.0
50.0
60.0
Strong decrease Slight decrease No change Slight increase Strong increase
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triggered the arrival of new challenges for the continuity of treatment and provision of
adequate quality services:
• adapting to the tele-information system for the online counselling and therapy
provision,
• making patients change their attitude towards the effectiveness of therapy via
the Internet and phone,
• building a therapeutic relationship at a distance,
• shifting from on-site to online group therapy,
• handling software and hardware issues e.g. making new purchases,
• possible therapist burnouts due to the lack of direct contact with patients.
Moreover, not all patients have technical capacity to participate in remote therapy,
which poses additional challenge in using new forms of treatment and counselling:
“The strongest decrease is in patients who participated in group therapy. 50% of group
therapy patients still attend the sessions, which are now held online”.
Figure 4. Have there been overall changes in the availability and provision of
harm reduction services in your country since COVID-19 containment measures
were introduced? (%) (N=35)
40.0
37.1
20.0
2.9
0.0
0.0
5.0
10.0
15.0
20.0
25.0
30.0
35.0
40.0
45.0
Strong decrease Slight decrease No change Slight increase Strong increase
10
As a result of the COVID-19 epidemic there was a sharp decrease in the availability
of harm reduction for active drug users. Harm reduction programmes implemented
additional measures aimed at active drug users. Clients receive protective equipment
such as face masks, disposable gloves and hand sanitizers. Information on the
infection symptoms and procedures to be undertaken in case of the coronavirus
emergency was distributed. Measures were taken to provide food for the poor and
homeless clients in collaboration with other organizations e.g. Wroclaw-based Salida
Foundation started serving hot meals and food rations at drop-in centres run by the
foundation. A significant limitation on benefiting from harm reduction programmes is
the fact that almost all drop-in centres for active drug users, except one in Wroclaw
run by Salida Foundation, had been shut down and street-based actions had been
limited as a result of the introduction of the new epidemic-related regulations: “As a
consequence of the ban on public gatherings we have limited access to individuals
who regularly used harm reduction services. Chaos is noticeable among active drug
users. They have become quarrelsome and tense. At the start of the epidemic we
observed more intensive drug use. New individuals in new places are emerging or
they are reporting to the drop-in centre in order to use the bathroom, receive food and
coffee”. However, harm reduction programmes are still distributing the drug use
equipment with the new means e.g. sterile needles and syringes as well as disposal
bins are home delivered. Despite the drop-in centres being shut, harm reduction
programmes distribute the equipment through dedicated windows. In addition, mobile
needle and syringe exchange services have also suspended their operations.
Outreach workers find it hard to reach those in need due to the ban on gatherings.
Harm reduction programmes are reporting higher client demand for food, which is
caused by the decline in income. Most sources of income of active drug users,
especially among the homeless, have ceased to exist. That is why food provision has
become one of the priorities of harm reduction programmes during the epidemic. The
new situation has particularly affected the homeless: “Deterioration of health is
especially noticeable among individuals who do not use night shelters. Such
individuals find it difficult to access dedicated bathing facilities, they are not able to
wash for many days or sometimes weeks, which results in very serious dermatological
conditions. Access to medical care is also limited. Consequently, more problems are
emerging such as mental crises or the intensification of drug abuse or deepening of
drug addiction”.
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The survey also included questions about which types of drug treatment services had
been suspended or largely limited due to the COVID-19 epidemic (Figure 5).
According to the surveyed institutions, residential facilities were the most affected by
the new situation. 85% of the responses indicated that residential treatment services
had been either suspended or considerably reduced. A slightly lower percentage
(80%) of the responses reported suspension and limitation of drug treatment at
primary healthcare centres, which contrary to residential treatment is not as
widespread. In Poland, drug treatment at outpatient clinics is most widely available.
65% of the surveyed institutions reported that such type of treatment had been
suspended or considerably reduced. It seems that the epidemic impacted the least the
availability of opioid substitution treatment (OST). 25% of the respondents reported
the suspension or considerable reduction of this treatment (OST) in Poland at
dedicated programmes while 20% at unspecialized outpatient clinics, which in Poland
basically means buprenorphine treatment.
Figure 5. Which drug treatment services have been discontinued or have
significantly reduced their traditional operations due to the COVID-19 epidemic?
65.4
25.0 20.0
80.0
70.0 73.9
84.8
37.5
Outpatient counselling and psychosocial
treatment (N=52)
OST in specialised outpatient treatment
centres (N=16)
OST in non-specialised outpatient
treatment centres (e.g. GPs, etc) (N=5)
Drug treatment in primary health care
settings (e.g. general practitioners)
(N=20)
Drug treatment in primary outpatient
mental health care centres (N=14)
Drug treatment in hospital-based
residential settings (e.g. psychiatric
hospitals) (N=17)
Drug treatment in non-hospital based
residential settings (e.g. therapeutic
communities) (N=28)
Drug treatment in custodial settings
(N=3)
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7. Opioid substitution treatment
It seems that the containment measures in response to the COVID-19 epidemic did
not affect the continuity of the opioid substitution treatment (OST) in the case of clients
already covered by this service. In the case of substitution treatment we intended to
measure the impact of the epidemic on new admissions as well as the continuation of
the treatment by those already in the system. 62% of the responses reported that the
COVID-19 containment measures had not affected the continuation of the opioid
substitution treatment by the patients already covered by it. 28% of the respondents
said that the COVID-19 epidemic exerted a slight negative impact; however, the most
of the patients were able to continue the substitution treatment. In the case of new
patients, the highest percentage of the respondents (41%) answered that the epidemic
had a slight negative impact; however, the most of new clients were able to enter it.
29% of the respondents reported a strong negative impact, which meant that fewer
drug users are able to enter treatment. It is clear that the epidemic mainly affected the
onset of treatment by new entrants. As it has been mentioned, methadone
programmes introduced new forms of distributing the drug for the clients: “Since the
beginning of the epidemic we have been dispensing 1 ration of methadone per 2
weeks for the majority of patients in order to reduce the possibility of patient-patient or
patient-staff contacts as well as the frequency of patients moving around the city”.
Figure 6. To what extent have COVID-19 containment measures impacted the
continuation of opioid substitution treatment (OST) for already receiving this
treatment? (N=21)
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Figure 7. To what extent have COVID-19 containement measures impacted the
initiation of opioid substitution treatment (OST) to new clients demanding or in
need of this treatment? (N=17)
8. Obstacles and challenges
The survey also featured questions about the main obstacles and challenges for drug
treatment services and harm reduction programmes. The challenges obviously include
the coronavirus-related health threats:
• Caring for the safety of drug treatment personnel by introducing procedures that
protect patients at the unit
0.0
9.5
23.8
4.8
61.9
0.0 10.0 20.0 30.0 40.0 50.0 60.0 70.0
Strong negative impact, but most clients are
still able to receive their OST as before
Strong negative impact and fewer clients
are now able to receive OST as before
Slight negative impact, but most clients are
still able to receive OST as before
Slight negative impact and fewer clients are
now able to receive OST as before
No change
5.9
29.4
41.2
5.9
17.6
0.0 5.0 10.0 15.0 20.0 25.0 30.0 35.0 40.0 45.0
Strong negative impact, but most new clients are still
able initiate a new OST
Strong negative impact and fewer new clients are now
able to initiate a new OST
Slight negative impact, but most new clients are still
able to initiate OST
Slight negative impact and fewer new clients are now
able to initiate OST
No change
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• Unlimited access to disinfectants and wide access to tele-counselling both in
the field of psychiatry and psychotherapy
• Adapting the infrastructure of drug counselling centres and wards to admit
infected patients (disinfection sluices, isolation rooms, protective equipment)
• Wide access to COVID-19 diagnostic tests, antibody tests, acquired immunity
tests
• Providing substitution treatment for quarantined or infected individuals
• Health checks for every patient entering the drug service building
(temperature, face mask control since the start of the epidemic, extra member
of staff at the entrance)
Another set of challenges were changes related to the new operating rules, which
translated into the new ways of working with problem drug users and their loved
ones.
• No contact with the patient’s family due to ward visit being suspended
• No group therapy
• Difficulty admitting first-time patients
• Building therapeutic relationship at a distance
• Considerable reduction of individual therapy sessions
As it has been mentioned a number of drug services started using the Internet to
work with patients, which triggers new challenges and problems:
• Not all patients have access to the equipment enabling remote therapy. Some
of them are reluctant to use IT devices.
• Maintaining contact with the patient might be challenging in the case of using
online work methods.
• Limited contact with the patient in case of IT network emergency or failure
• No skills to use IT resources both among therapists and patients.
Drug services which completed the questionnaire also reported problems related to
the functioning of the whole system and lack of access to some forms of help. To a
large extent, cooperation among various services in the field of treatment and help
was reduced:
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• Most residential treatment centres stopped admitting patients
• Detoxification admission limitations were introduced
• Continuing treatment in residential treatment centres after completing
detoxification was limited
• Limiting access and collaboration with other welfare and medical services,
day-care centres and night shelters due to the closure of some of these
service
• Some facilities stopped operating as they had been transformed into
dedicated COVID-19 containment units e.g. detoxification ward at hospital in
Nowowiejska Street in Warsaw
The budgets of harm reduction programmes and drug treatment units were also
burdened with more purchases (face masks, gloves, disinfectants, fuel) and other
unforeseen expenses intended to maintain operations and help drug users during the
epidemic.
9. Drug users and drug market
According to the information by the Krakow-based Monar Association, two groups of
homeless individuals benefiting from harm reduction services can be distinguished.
Their situations differ significantly:
• Individuals placed in night shelters and other similar facilities. Their health is
improving.
• Individuals outside night shelters and similar facilities. Their health has
dramatically deteriorated. Due to the epidemic, homeless people find it difficult
to access dedicated bathing facilities, which results in very serious
dermatological conditions. Access to medical care is also limited.
Consequently, more problems are emerging such as a mental crises or drug
abuse.
Based on the data collected in the course of the survey, currently (March - April) we
do not observe significant developments across the country in terms of access to
drugs. Naturally, there are situations where some drugs are in shortage e.g. in the city
of Wroclaw there was a fall in the availability of methamphetamine trafficked for
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Czechia following the closure of borders. Along with the development of the epidemic
and borders still being closed the situation might worsen. In Krakow, the lack of new
psychoactive substances (synthetic cathinones) was reported. Another development
observed was the drop-in drug prices, which is a result of the lower purchasing
capacity of harm reduction clients, who are mainly injecting drug users.
10. Summary and conclusions
The preliminary findings of the survey have shown that the coronavirus epidemic has
considerably affected the Polish drug services, especially in terms of ensuring the
continuity of services at the adequate level. The operation of inpatient clinics
(residentials treatment) and drop-in centres (harm reduction daily centre) has been
limited the most. It seems that the availability of the outpatient care has also declined.
As a consequence of the epidemic, drug treatment units, especially drug counselling
centres, were forced to greatly transform their operations and transition to the online
solutions. It is clear that the epidemic has led to the suspension of admitting new
patients to drug treatment. It seems that the opioid substitution treatment has been
least affected by COVID-19. However, it does not mean this field has not suffered. The
results of the survey allow for concluding that methadone programmes are able to
continue their basic operations to the large extent. The key change in the operations
of methadone programmes was the decision to dispense methadone for longer
periods. However, methadone programmes limited or discontinued other services e.g.
psychotherapy. It is worth noting that substitution treatment has seen a higher demand
for its services, which was the consequence of opioid users being deprived of income
as a result of the epidemic. The lack of financial resources made drug users decide to
enter opioid substitution treatment.
In the field of harm reduction we also observed serious operating limitations caused
by the introduction of the epidemic-related regulations. Harm reduction programmes
have developed new ways of care provision such as distribution of food or protective
equipment. Moreover, they have faced new challenges such as caring for the
homeless while the majority of aid institutions have significantly limited their
operations.
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Moreover, regional variations in the incidence of COVID-19 show that preventive
measures could vary regionally considering the different scale of the epidemic in the
respective provinces in Poland. It is worth noting that the majority of drug services
swiftly started to introduce counselling and therapy online or over the phone. In
response to COVID-19, 86% of the drug services (N=69) introduced remote services
in the field of drug treatment or harm reduction (telephone, video calls, online access).
It will surely be a new quality in the offer of some facilities following the end of the
epidemic. As a result the drug treatment system might be supplemented with new
forms of client work.
It also should be mentioned that drug-dependent individuals, mainly homeless ones,
have been particularly badly affected when the COVID-19 containment solutions were
introduced. Harm reduction programmes were forced to undertake new measures to
meet the basic needs of such individuals e.g. distribution of food and protective
equipment. As a consequence of the COVID-19 epidemic, individuals, who were
previously considered excluded, were pushed further beyond society’s boundaries. An
inadvertent result of this epidemic is the situation where drug-dependent individuals
who have lost their livelihoods begin to seek opioid substitution treatment. The
epidemic has thus become the motivation for entering drug treatment. Another COVID-
19-related development were the changes introduced in a number of substitution
treatment programmes in Poland. The programmes started giving out substitution
drugs to their patients for longer periods e.g. two weeks. It also poses a challenge for
the clients of those programmes. They receive a large single dose of methadone,
which requires that they must be able to exercise self-control in order to take the drug
as indicated.
These findings are the first attempt to analyze the drug services system in the wake
of the epidemic. The current situation, as every crisis, gives us a chance to learn
lessons for the future. The entire healthcare system, including drug services, was
faced with the lack of procedures in the case of the epidemic such as COVID-19.
Therefore it is worth considering the creation of such procedures for the future, based
on the experiences at hand. It might make us better prepared for another wave of this
epidemic, if it happens, or an entirely new threat.
Contact to the main author of the report: artur.malczewski@kbpn.gov.pl
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