Situation: During the COVID-19 pandemic, many face-to-face support services have become unavailable. People who use drugs, one of the most stigmatised segments of the population, have been affected.
In fact: The pandemic has increased opportunities to reduce harm resulting from drug use. Against the backdrop of quarantine measures in Russia, an increase in the active development of work through online platforms with people who use drugs has begun. The available results have already demonstrated their effectiveness.
HSE University researchers together with specialists from the Humanitarian Action Charitable Fund (St. Petersburg) and the University of Michigan School of Public Health (USA) studied the specifics of remote work with Russian people who use drugs to reduce the harm of drug use. They discovered that the use of online platforms increases the likelihood of people who use drugs to seek help. Online platforms also serve as a kind of ‘gateway’ for people with problematic drug use to receive a wider range of qualified help. The authors concluded that remote work in this field should be developed and built upon in an ongoing systematic way even when the threat of coronavirus recedes. The results of the study are published in the Harm Reduction Journal.
All over the world, people who use drugs face many health hazards. These include, for example, contracting HIV, hepatitis C, vein damage, overdoses, and numerous psychological problems.
Drug-related harm reduction programmes, often run by NGOs, are aimed at combating that harm. Humanitarian Action is one such non-governmental organisation in Russia. Founded in 1997, Humanitarian Action provides accessible services for people with substance use disorders, that are designed to reduce the severity of the negative consequences of drug use. These services include:
exchange and disposal of used syringes and needles;
provision of motivational packages containing sterile syringes, alcohol wipes, water for injections, ointments, bandages;
help with express testing for HIV, HCV, HBV, and syphilis;
support and referral of clients to medical centres for HIV diagnosis confirmation and initiation of antiretroviral therapy (ART);
assistance in accessing treatment for opioid drug overdose;
case management in accessing social, medical, and legal services.
These services are provided at no cost to individuals when they visit the NGO’s mobile units. The NGO has recently added web outreach work to its activities in order to increase the programmes’ accessibility, including for people who use drugs who do not attend the mobile units.
One of the main online services that the NGO actively uses to interact with people who use drugs is Telegram instant messaging. As of June 2020, the platform had 30 million active users in Russia.
The researchers used the example of a St. Petersburg NGO to analyse the most frequent requests received via Telegram from people who use drugs, the difficulties they face with people who use drugs and the specialists assisting them, and the prospects for the development of a remote format of working in the field of drug use harm reduction.
Researchers have analysed the working reports of NGO staff in 301 cases of web outreach work. The period of contact with people who use drugs in these cases was from November 2019 to June 2020. These included a description of the clients’ needs as well as the nature of the assistance provided.
In addition, the researchers conducted four semi-structured interviews with the NGO staff and the deputy director in June 2020, to study the process of web outreach in terms oforganisational processes. A thematic analysis method was used in the study.The study was approved by the Ethical Committee of the St. Petersburg Association of Sociologists.
It turned out that the most frequent online requests for help from people who use drugs concern:
minor complications arising from injecting drugs;
information regarding harm reduction, HIV, and HCV;
information regarding detoxification at home;
information regarding the COVID-19 pandemic;
The study provides a comprehensive picture of how the NGO works with people who use drugs. As a rule, NGO clients direct their question to a group chat. If the answer to a question may be important for all participants in the group chat, then the NGO specialist responds in the chat itself. If the question is of a sensitive nature and/or private communication is required, then the NGO staff member contacts the client privately.
Sometimes other participants may provide answers in the general group chat. The NGO staff will then moderate the discussions in order to maintain a safe and comfortable space.
‘… As a moderator I supervise such discussions and in the event of disrespectful content […] I intervene and explain that this is not a space for insulting each other [...] we want this space to be as safe as possible’ (from the interview with Deputy director of the NGO).
The most frequent enquiries concern minor complications related to drug use. These fall into the category of minor complications when face-to-face medical care is unnecessary. In fact, they refer to such unpleasant consequences of injecting drugs as collapsed veins, venous bleeding, varicose veins, venous ulcers, and rashes. People who use drugs describe their problems text and/or with photos. The specialists’ answers are verified by medical professionals before they are sent. In cases where a web outreach worker feels that more skilled medical assistance is needed, the client will be directly contacted by a doctor working at the NGO.
Other common requests for help relate to information on how to reducing the harm and risk of contracting HIV or hepatitis — for example, centres where antiretroviral therapy (ART) is available. Some clients enquire through the NGO staff about the ways in which HIV and hepatitis are transmitted.
A less common, yet still important topic of enquiry is detoxification at home. Only a few clients have shown interest in this topic, the researchers noted. NGO staff informed people who use drugs about the potential risks, as well as providing general information on how detoxification is carried out in medical settings and contact information of specialists with whom clients can get in touch.
Since April 2020, a number of COVID-19 pandemic-related needs have emerged. Specifically, clients have asked how they can get help during the pandemic, such as details of rehabilitation programmes or detoxification services.
Another frequent reason people who use drugs ask for help via Telegram is the need for psychological support. Among the most common requests are: difficulties in combatting drug addiction, anxiety about the repercussions of quarantine measures (e.g. drug shortages), anxiety about the death of a partner, worries about possible infection. If the clients do not request the help of a certified psychologist, the web outreach workers provide them with advice based on their personal experience and the contact information of the NGO staff who can be contacted for additional help.
During the study, the authors identified a separate block of enquiries that cannot be fully handled online because they require the client to be physically present. Such requests occurred in nearly a third of the cases analysed. For example, clients needed personal assistance in obtaining ART at a specialised centre, receiving ART in a home setting, personal assistance with hospitalisation for detoxification and rehabilitation, support from a certified psychologist, assistance with obtaining documents or confirming incapacity to work. In such cases, people who use drugs were invited to the NGO's mobile units for face-to-face assistance.
Other requests that could not be processed online included severe complications from intravenous drug use, such as severe venous bleeding and lesions, swelling, and skin abscesses. In addition, people who use drugs sought help via Telegram related to HIV and hepatitis testing. In these cases, clients received instructions on how they could be tested.
The smallest number of enquiries was related to overdose. For these requests, the NGO created a special Telegram bot that provided clients with the necessary information about symptoms, treatment options, and the contact information of a doctor who could provide online assistance. In two of the four cases, clients had to call an ambulance. The centre’s staff stayed in touch with clients until the paramedics arrived.
The researchers determined the difficulties that arose during communication between people who use drugs and the professionals assisting them online. These include, for example, sending voice messages when the staff member cannot listen to them or messages at night when the staff member is not available. Sometimes clients send illegible messages because they cannot formulate the request correctly. The centre's staff then offer to call them back, but further dialogue may not take place.
‘After I suggest that we speak over the phone, some send me their phone number or ask me for mine. Other leave the chat, and no longer reply’ (NGO specialist).
Some staff noted that phone calls are the next step in communication between the client and the NGO specialist.
‘Sometimes it is hard because you need real-life communication to understand how a person feels [...] When you talk to them in person, you gauge their reactions, and it’s easier to monitor certain things [...], [for example] whether they are ready to open up. In Telegram, I don’t see the person and it’s hard for me to do my job effectively if a person doesn’t call me.’ (NGO Specialist).
Nevertheless, as the research has shown, Telegram serves as a kind of gateway to harm reduction for people who use drugs. From the point of view of the NGO’s staff, it is a convenient ‘first step’ that clients can take to receiving assistance. Importantly, the availability of such services increases the likelihood that people who use drugs, who are not ready to discuss their drug-related problems face-to-face, will contact specialists.
Researchers have concluded that existing online services aimed at reducing the harm of drugs could be improved. One of the possible solutions, they believe, is to automate some of the work, for example by using more bots that clients could use, including at night. ‘However, not all services can be automated; therefore, it may be necessary to hire employees who can respond to clients during the night. This is especially important when it comes to critical situations such as overdose,’ says the study.
The researchers also suggest that an effective way to develop online harm reduction services could be to increase their presence on darknet forums.
Every year in Russia, thousands of people die and suffer critical complications related to drug use. For example, according to data provided in a report by the State Anti-Drug Committee, 4,569 people died from drug use in Russia in 2019, an increase of 2.8% compared to 2018. There were also 18,053 cases of drug poisoning, an increase of 10.5% compared to 2018. Meanwhile, about half a million people (423,400) with mental and behavioural disorders related to drug use were registered in Russia in 2018, according to the Ministry of Health of the Russian Federation. Among them, 5,400 were minors.
During the pandemic, many services, including those related to healthcare, have become difficult to access — especially for stigmatised groups. In this context, online services aimed at reducing the harm of drug use are of particular importance.
The findings of the study show how effective web outreach work with people who use drugs can be. However, according to the authors, further research in this area is needed. It is important, for example, to understand the motivations behind the refusal of drug addicts to continue communicating with specialists by phone, to clarify their needs, and to develop new ways to reduce the harm of drug use.
Peter Meylakhs, Senior Research Fellow, International Centre for Health Economics, Management, and Policy, HSE Campus in St. Petersburg
Arsen Davitadze, Visiting Lecturer, HSE University – St. Petersburg
Aleksey Lakhov, Humanitarian Action Charitable Fund (St. Petersburg)
Elizabeth J. King, University of Michigan (USA)