During the first two weeks of March, IHRC staff watched closely as organizations around the country began to make decisions reflecting the pandemic and the need to prevent transmission. For community-based Harm Reduction organizations, no matter how small or how under-resourced, one thing is for sure: Our services are critical to a particular subset of our community. During March 2020, it did not occur to us that we would close or suspend our direct service program. We simply made adjustments and took actions to ensure that our volunteers, staff, and clients could engage in services as safely as possible. Daniel Raymond, a long-time leader of the national Harm Reduction Coalition, participated in an episode of the podcast Narcotica in the early days of the COVID-19 response. His words were almost a call to action: for harm reduction service providers to mobilize quickly, to get out into the community and stay in touch with the people we care for and who care about us. Since early March, we have closed our program on two days due to employee illness, but are proud to have continued operating with no cases of illness reported among our client-base, volunteers, or staff.

Initially our office was quiet. The number of clients we served in March reached its lowest number ever. We made deliveries and connected with clients via the hotline, but the typical steady stream of individuals flowing in and out of our office was gone. And that was an okay thing – we shut down our drop in center and permitted just one client to enter our building at a time.

Micro Goals:

• Enforce and adhere to guidance for hygiene, PPE, physical distancing, etc while providing direct services in order to keep staff, volunteers, and clients safe and healthy.
• Respond to client need while maintaining opportunities for precautions – eg. increase home deliveries.
• Maintain client services in order to prevent a spike in overdose deaths, HIV cases, HCV transmission, and bacterial infections.
• Provide clients with accurate, trustworthy information about COVID-19 so that they may take appropriate preventive measures.
• No COVID-19 cases among IHRC’s client, volunteer and staff community!!

(Source: ACLU Iowa)

Jails (and prisons) are widely recognized by both medical and public health experts as ideal locations for viral infections to spread. For a virus like COVID-19, we could not create a more perfect environment for the bug to achieve its evolutionary goals: replicate inside the host and spread to as many new hosts as possible. Those who have been incarcerated in a jail or a prison, like many of the individuals we work with every day at the Iowa Harm Reduction Coalition (a public health nonprofit that works to prevent infectious disease and overdose related to drug use), will tell you that there is little hope of maintaining a distance of six feet between inmates. Jails and prisons are crowded and human beings are living, eating, sleeping, breathing, and showering in very close proximity to one another. That’s why in New York City’s jails, the COVID-19 infection rate is 3.6% (as of Monday, March 30). This rate is almost double that seen four days prior.

On March 20, a total of 26 Iowa advocacy organizations sent a letter to state and county officials recommending that they follow the advice of public health experts to make changes to Iowa’s criminal justice and legal systems during the COVID-19 pandemic. The letter urges officials “to partner with local public health experts in developing informed, immediately actionable steps to ensure that public safety and public health are as protected as possible.” This includes reducing jail populations by avoiding making new arrests in cases of low level, non-violent crimes, releasing people who are held merely because they cannot afford bail, and working to parole as many prisoners as possible.

Some of the highlights of the letter’s recommendations include:

• • Limit the number of people being arrested. Issue citations and tickets rather than arrests.
  • County attorneys and judges should use their discretion to limit the number of people put into jail, including reducing those held on pre-trial detention. They should also be especially mindful of inmates’ ability to post bail: 87 percent of the people in Iowa county jails are there because they don’t have enough money to post bail.
  • County attorneys also should dismiss cases with minor offenses, such as drug possession.
  • County jails should release people who would be released in the next 60 days anyway.
  • Officials should limit the number of people who are detained or incarcerated for technical rule violations while on probation, such as testing positive for alcohol or drugs or missing a parole appointment.
  • The governor should commute sentences for anyone whose sentence would end in one year anyway. She should commute the sentences for people whose sentences would end in two years who are especially vulnerable because of heart disease, diabetes, lung disease, or otherwise have a compromised immune system.

In addition to the ACLU of Iowa, organizations signing the letter are:
Iowa-Nebraska NAACP; Iowa Coalition Against Sexual Assault; Quad Cities Interfaith; Latinos Unidas para;; un Nuevo Amanecer; Iowa CURE; Iowa Citizens for Community Improvement; Project Iowa; St. Paul AME Church; League of Women Voters of Iowa; Inside Out Community Reentry Community; League of United Latin American Citizens (LULAC) of Iowa and LULAC national; NAMI Iowa; American; Friends Service Committee/Iowa Immigrants’ Rights Program; Des Moines Showing Up for Racial Justice; The Image Program; One Iowa; Rape Victim Advocacy Program; Interfaith Alliance of Iowa; Transformations Iowa; Iowa Coalition Against Domestic Violence; Transgender Voter Network; Regret No Opportunities; Just Voices Iowa; Iowa Harm Reduction Coalition

In late March 2020, the epicenter of the global COVID-19 pandemic was a New York City jail. While New York may be one of the most crowded cities in the world, that isn’t necessarily why COVID-19 has emerged in its jails. Jails (and prisons) are widely recognized by both medical and public health experts as ideal locations for viral infections to spread. For a virus like COVID-19, we could not create a more perfect environment for the bug to achieve its evolutionary goals: replicate inside the host and spread to as many new hosts as possible. Those who have been incarcerated in a jail or a prison, like many of the individuals we work with every day at the Iowa Harm Reduction Coalition (a public health nonprofit that works to prevent infectious disease and overdose related to drug use), will tell you that there is little hope of maintaining a distance of six feet between inmates. That’s why in New York City’s jails, the COVID-19 infection rate is 3.6% (as of Monday, March 30). Almost double the rate four days prior.

On March 20th, the Iowa Harm Reduction Coalition, along with 26 other organizations, signed onto a letter that called on Iowa’s Governor, Sheriffs, County Attorneys, and Department of Corrections Officials to take vital steps to prevent COVID-19 from incubating in Iowa’s jails and prisons. The letter recommends a number of other strategies that can be put in place to reduce the number of people who are incarcerated – a figure that currently sits at nearly 16,000 Iowans on any given day. We called upon our County Attorneys and Sheriffs to implement these recommendations as soon as possible.

The choice to ignore these recommendations will have unfortunate consequences on our entire community – not just the individuals who live on the inside of Iowa’s correctional system. The young woman arrested for possession of marijuana may transmit COVID-19 to her cellmate, or the officer who processes her upon arrival at the jail. From there, the virus can continue to spread exponentially within the jail and across the general community. Those working and living in Iowa’s prisons and jails must be afforded the same opportunities to practice social distancing as the rest of us. All of our lives depend on it.

Building on the momentum of the ACLU of Iowa’s leadership and the recommendations made by the coalition of 26 stakeholders, IHRC worked to leverage out networks and mobilize advocates to connect with county-level leadership. Our goal? To express the deep importance of COVID-19 prevention initiatives to the broader public, particularly when such initiatives are applied within the criminal justice system. During the final week of March, nearly 200 individuals participated in an e-mail based advocacy campaign, urging county sheriffs to implement the ACLU’s recommendations.

On March 31, SAMHSA and the Drug Enforcement Agency (DEA) released guidance providing flexibility to prescribe buprenorphine to new and existing patients with opioid use disorder via telephone by otherwise authorized practitioners without requiring such practitioners to first conduct an examination of the patient in person or via telemedicine.
These changes are significant. Medication Assisted Treatment (MAT), which includes methadone, suboxone, and naltrexone, is tightly regulated by SAMHSA and the DEA and has historically been regulated through policies that are both restrictive and unique within medicine. One provision of this policy was to require MAT patients be seen in clinic in order to receive treatment and prescription refills. Advocates have long bristled at this policy, especially in states like Iowa, where the red tape surrounding physician licensing to prescribe buprenorphine means that few providers in Iowa treat MAT patients, and many patients must drive 2-4 hours one way to the nearest MAT provider. Advocates have seen telehealth as an ideal for the expansion of MAT services in rural states, noting that such a strategy will be key in mounting a significant response to the overdose crisis. In response to the global pandemic and the need to keep patients away from hospitals and as many people in their homes as possible, federal policy that prohibited the prescribing of suboxone in telehealth-based patient care was suddenly removed.

On May 1, 2020 in Nature Medicine, Dr. Sarah Wakeman, a well respected Addiction Medicine Physician at Harvard University wrote in Nature Medicine, “Crisis leads to opportunity. COVID-19 presents unique and urgent challenges. However, it also presents an opportunity to create a healthcare system that truly addresses the needs of vulnerable populations, such as those with opioid use disorder. We must first act quickly to stave off a substantial increase in overdoses, an impending crisis on top of a crisis.”

Her message was clearly articulated in the piece’s title: “An overdose surge will compound the COVID-19 pandemic if urgent action is not taken”

She was reflecting in particular on the unique vulnerability faced by people who use drugs in light of COVID-19. She goes on to state:

“In the USA and around the world, the COVID-19 pandemic arrived as the population was fighting a devastating opioid overdose epidemic. Urgent and decisive action is needed to protect particularly vulnerable populations, such as those with opioid use disorder, to prevent a compounding effect on public health.

As the global spread of the coronavirus SARS-CoV-2 continues, the pandemic’s impact on people who are already marginalized and vulnerable will be profound, and the ‘knock-on’ effect on public health will be severe. This is particularly true of people with opioid use disorder.

Those who are most vulnerable in our society are at greater risk of opioid addiction at the best of times. Under the preventive social distancing that is needed to limit the spread of SARS-CoV-2, but also exacerbates social isolation and despair, both of which are known risk factors for the development and exacerbation of addiction, they are at greater risk than ever. The odds are stacked against those living with opioid use disorder during this outbreak with heightened risks for infection with SARS-CoV-2 and also for overdose. In part because of many countries’ decision to criminalize drug use rather than offer treatment, rehabilitation, harm reduction and compassion, those who suffer from opioid addiction are also at greater risk of incarceration, homelessness and severe mental illness, predicaments that do not enable proper social-distancing measures and frequent hand washing. Co-occurrence of chronic medical conditions often predisposes these people to more-severe forms of COVID-191. Lack of economic opportunity also may predispose those needing to procure opioids to turn to illegal activities, further exacerbating an already difficult situation of rampant COVID-19 in US prisons.”

Jails and prisons have long been identified as community spaces that are at increased risk for infectious disease transmission. Physical (and social) distancing are oftentimes impossible in carceral settings, and people in these settings exist in close proximity to one another. The COVID-19 pandemic has brought heightened attention to the living conditions in jails and prisons. While COVID-19 cases are not expected to peak in Iowa until early to mid May, carceral institutions in other states have become the pandemic’s epicenter. New York City’s jails have the highest COVID-19 infection rates in the world, with 9.1% of Rikers Island residents testing positive as of April 20, 2020. Since early March, many Iowa counties have taken significant steps to reduce jail crowding and promote social distancing within court houses. On April 18 the first resident of Iowa’s prison system tested positive for COVID-19, leading Governor Kim Reynolds’ office to implement a series of new preventive measures for Iowa prison facilities. Strategies implemented at the state and local levels seek to prevent outbreaks from occurring in Iowa’s county facilities and reduce the number of law enforcement personnel, jail staff, incarcerated individuals, and criminal justice system professionals from contracting the virus and then spreading it into the community. But with Iowa’s projected COVID-19 peak still weeks away, some public health and health care professionals remain concerned regarding the preparedness of Iowa’s jails and prisons to adequately address the pandemic. This speculation is due in part to wide variation across Iowa’s 99 counties in measures implemented to prevent COVID-19 transmission in criminal justice settings. Despite few cases documented in IA prisons, some public health officials suggest that more action from the Governor’s office is needed to prevent the spread of the pandemic in state facilities.

As COVID-19 first hit states around the U.S., Governors and Public Health administrators responded with statements that made clear that syringe service programs (SSPs) are a critical component of public health infrastructure, and that this crisis will be framed as an opportunity for the repeal of some of the more archaic and non-science based components of syringe access policy.

In Maine, the American Medical Association pressured the Governor to issue an Executive Order that would repeal the state’s 1-for-1 policy, a vestige of the early days of syringe exchange programming in the U.S., where individuals could only receive one syringe if they were willing to turn in an equal number of used syringes. This order was quickly brought to the Governor’s desk, signed, and implemented.
AMA urges states to adopt new Maine needle, syringe exchange policy

In Pennsylvania, SSPs have operated legally for more than 25 years in the state’s largest cities. But the state is one of only a few that have not modernized its drug paraphernalia code and declared SSPs legal at the state level. PA’s Governor recognized the critical role SSPs play in sustaining life, and despite the programs not being legal in the state, declared SSPs an essential service and their workers essential personnel.
Syringe exchanges deemed ‘life-sustaining’ during Pa. coronavirus shutdown, raising hopes for eventual legalization

In Illinois, public health workers have recognized the unique vulnerability faced by people who use drugs during COVID-19, particularly those who smoke stimulants and are likely to share stimulant smoking equipment. Funds have been allocated for the purchase of safer smoking kits, in order to prevent transmission of the coronavirus in this high risk group.

In 2019 an estimated 12,000 Iowans suffered from Opioid Use Disorder (OUD). The Substance Abuse and Mental Health Services Administration (SAMHSA) recognizes the combination of counseling and behavioral therapy with FDA-approved medications such as methadone and buprenorphine/Suboxone for treatment of OUD. In order to prescribe buprenorphine/Suboxone, the federal Drug Addiction Treatment Act of 2000 mandates physicians complete 8 hours and advanced practice providers complete 24 hours of training to receive a waiver. Once they acquire this “X” waiver, providers can prescribe to a maximum of 30 patients in their first year, 100 patients in their second, and up to 275 patients thereafter. Iowa currently has 194 X-waivered providers in 35 of our 99 counties, and 8 methadone clinics in 5 counties. These regulations create enormous barriers to life-saving treatment for vulnerable Iowans. Now, with the expansion of telehealth due to COVID-19, a variety of state and federal restrictions to treating OUD have been lifted and Medication Assisted Treatment (MAT) clinicians have had to adapt.

The Substance Abuse and Mental Health Services Administration (SAMHSA) announced on March 16th that due to the COVID-19 pandemic it will exempt Medication Assisted Treatment (MAT) Clinics from requiring monthly (for buprenorphine) or daily (for methadone) in-person physical exams on patients before prescribing them medications for Opioid Use Disorder. This allows providers to treat their patients with life-saving medication without requiring them to travel for regular check-up visits and risk viral exposure. SAMHSA has said these exemptions may cease after the pandemic, but these changes give MAT supporters a unique opportunity to advocate for continued deregulation and reduction in barriers to care. This webinar will feature public health experts, state and federal government officials, Iowans affected by Opioid Use Disorder, and MAT clinicians from multiple Iowa communities. Speakers will discuss the changing barriers to MAT access during the COVID-19 pandemic and highlight areas where further action is needed. This webinar will be recorded and a written summary with key recommendations for next steps will be disseminated.

Our hope is to provide a space for healthcare professionals, policy makers, and those affected by OUD to have a discussion about how we can capitalize on this rapid restructuring of MAT services. The goal of this webinar is to identify a set of recommendations that individual speakers would like to make for stakeholder groups at federal, state and local levels.