Getting what you need in the middle of the chaos becomes nearly impossible.
One often-overlooked group who were also severely impacted by Hurricanes Harvey and Irma: drug users. Frequently without the resources to evacuate, they had to stay behind. And with the fear of not knowing if they'd have enough drugs or be able to access the medication that prevents withdrawal symptoms, people with addiction were left to possibly take part in risky behaviors, like sharing syringes. Meanwhile, the stress and anxiety of a natural disaster can cause relapse.
Recent reports have surfaced about efforts to help this group through a disaster by dosing out extra medication to prevent withdrawal (such as methadone for heroin users), overdose reversal kits (Narcan) that can be life-saving, or giving out additional clean syringes. We spoke Enrique Rodriguez Pouget, Senior Methodologist at the Center for Policing Equity in New York City, who led research on the impact Hurricane Sandy had on injection drug users.
What are the challenges that people with addiction face during a natural disaster like a hurricane?
They have all of life's challenges that anyone has [during a hurricane]. Beyond that, it may be a triggering mechanism. They may be self-medicating for anxiety, trauma, or, PTSD. They may be more vulnerable to a relapse because of the increased stress.
In order to manage dependence issues, planning is really important, whether or not someone is in treatment. In treatment, if they're in a methadone program, it's important to plan for medication doses if the clinic won't be open. They might have to travel to a different city, and that may require a medical referral for treatment. If you're dependent on opioids, withdrawal is bad enough. You don't want someone to experience withdrawal while also evacuating from a flood. And while they may be going to a public place [like a shelter] where doctors are available, they may not be able to start you on medication therapy for dependence during an emergency.
If you're not in treatment, withdrawal is even worse. Research shows that drug users who plan for the future—thinking about the week or weekend in advance—helps avoid withdrawal and helps users avoid having to share injection equipment or syringes. This preparation makes them more likely to inject with a sterile syringe, not go through withdrawal, and they are less likely to turn to street drugs.
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If planning is so important, how well do cities prepare for this?
People don't plan for this. Only since Hurricanes Katrina and Sandy is there an increased awareness of health clinics needing to prepare for evacuation. However, things are changing because disasters seem to be getting worse or having a greater impact. As far as drug treatment, [cities] are just beginning to recognize the need for planning for drug treatment in the context of disasters. There isn't a lot of research literature on this; you can't exactly conduct randomized experiments.
If people with addiction know they need to prepare, will they be able to?
Not everyone is equally able to prepare, especially where there are disparate resources. You may be told to evacuate, but if you don't have a car or money for traveling, that's not realistic. It's hard enough to ask someone who has these resources to leave. You need more support. And during an emergency like a hurricane, you may lose cell connection. You may be totally separated from the support system you depend on.
What are the health risks for drug users during a hurricane?
Not everyone knows the risks of sharing syringes or drug preparation equipment, which includes a container of water to dilute the drugs, cotton, and water itself. Sharing those implements can transmit HIV and make it much easier to acquire hepatitis C—and it's very easy to acquire hepatitis C. It all depends on if the people you're using with are affected themselves. On their website, the CDC recommends using a sterile new syringe with each injection. One problem is acquiring enough sterile syringes for their injections. Syringes have limited availability; in some states they're not available at pharmacies or you need a prescription. In some areas, carrying around syringes can be evidence of selling drugs, so people are wary about carrying a lot of syringes.
When in an evacuation scenario, as we found in our paper [a 2016 study published in the journal Substance Use & Misuse that looked at 300 injection drug users in the aftermath of Hurricane Sandy in New York City in 2012], people injecting drugs did not have sufficient syringes to inject safely or they were forced to share and they did that with people they didn't normally [whose HIV and hepatitis C status they were unaware of]. Our study didn't look at if this increased rates of transmission, but presumably there is a substantial risk for hepatitis C and HIV epidemics based on events like this.
Some clinics are able to give out more days' worth of methadone in preparation for these events. How does that happen?
While I'm not up on the state laws, methadone or buprenorphine (the pill form of medication for opioid dependency) are among the most highly regulated drugs in the country. There are a lot of limitations and specialized training for these clinics. Some states and municipalities got waivers to allow patients to get several take-home doses. In general, though, these medications are underutilized. For people who are dependent, there's an enormous unmet need for medication-assisted treatment for opioid dependency. People are walking around with illness that needs treatment, but [with a hurricane], everything is worse and it takes a while to get back into treatment [afterwards].
What steps do authorities take to rectify this issue?
In general, the resources available for people with substance abuse problems are not sufficient. Syringe exchange programs are severely underfunded. This is one of the public health programs where mounds of evidence support their utility. Research shows these programs don't increase the risk of HIV transmission, and they reduce the chance of transmission. Still, it's so stigmatized. In some states, it's not allowed by law or severely limited.
Authorities may not be able to prevent people from using drugs, but they can make it as safe as possible. How important is that?
That's the philosophy behind the harm reduction movement. People may or may not stop using drugs, even under treatment. It's important to keep them safe even while they continue to use drugs or if they enter treatment or not. And with syringe exchange programs, you make it safer for everyone else, including [drug users'] spouses and sex partners. There's very little debate whether these programs are effective or useful, but there's political opposition due to stigmatization. Hopefully there's increasing awareness that there should be a public health response.
What else may prevent drug users from getting the help they need?
There are disparate resources and sometimes this issue is racially charged. Black people looking for help are described as "looters." White people looking for help are "desperate citizens looking for help." Any inequalities that existed before tend to be magnified after [a natural disaster]. Drug users are stigmatized and that's not helpful during a disaster. People who use drugs are every bit as worthy of their civil and human rights as anyone else. They deserve our respect, treatment, and care just like anyone else.
People are resilient and in our studies, they helped and rescued each other. [It's important] to know that happens when people use drugs. They are just like anyone else. They're part of the social context of our communities like everyone else.
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