Studies conducted in the early months of the COVID-19 pandemic have shown that drug services continue to experience shortages in responding to pandemic-induced changes (Dunlop et al., 2020; European Monitoring Centre for Drugs and Drug Addiction 2020). Meanwhile, people working in service delivery and health workers in general are especially vulnerable to “[h]azards [that] include pathogen exposure, long working hours, psychological distress, fatigue, occupational burnout, stigma, and physical and psychological violence” (WHO 2020). Other studies from the Eastern European region have also shown that drug treatment services are under serious constraints and require detailed interventions and the support of local governments (Deilmizade and Moghanibashi-Mansourieh 2020).
Our research investigated challenges in clinical treatment, methadone maintenance services, psychotherapeutic counselling, and harm reduction stations operating in the city of Baku. Drug treatment services in Azerbaijan remain basic, often poorly adapted versions of Western harm reduction measures, and lack trained medical staff capable of quality control (Azbel et al. 2015; Stöver 2009; Sultan 2019). These factors have reduced the efficiency of otherwise highly effective harm reduction services for vulnerable groups such as people who inject drugs, as well as those in carceral institutions or engaged in sex work (Altice et al. 2016; EHRA 2020), putting both professionals and patients at risk. This raises a concern about the ways in which the pandemic might affect the work of professionals and thereby those receiving drug treatment.
In this study, we asked what has the pandemic enabled / disabled in health service provision in Baku for people who use drugs and what are the effects (if any) of government policies and instructions for health workers in handling drug treatment-related services during the pandemic? Our interests lay with SARS-Cov2 screening and testing for healthcare professionals, conditions in the provision of methadone maintenance treatment (MMT), workplace safety and access to information, wellbeing, and physical health, as well as the functionality of various types of counselling such as mental health, and blood-borne viruses such as HIV and hepatitis-C (HCV).
Data collection and materials
The study was carried out over 8 weeks in 2020 between June and July and was approved by the ethical committee of the Azerbaijan Social Work Public Union (ASZWU-02/22/05/2020). For the first stage, nine professionals were recruited for focus group interviews of which one participated in a pilot interview. Eight professionals took part in the first stage that was carried out during June in three focus group meetings each lasting 90 minutes on average. Despite the small sample size, the interviewed professionals (referred to as P1, etc. at the end of the quotes) were able to provide thick descriptions and engage in lively exchanges due to personal acquaintanceships and professional collaboration in their day-to-day practices. Follow-up interviews continued on a single participant basis, which was the second stage of data collection. The second stage involved outreach workers and leaders of local 12-Steps fellowships. The questions aim to contribute to the ongoing data collection and intend to provide first-hand empirical results from Azerbaijan hoping to provoke more engagement in Eastern Europe and the South Caucasus in drug treatment and harm reduction services. The interviewees answer semi-structured narrative-style questions. Moderators often prompt based on the narrated individual experiences.
Findings: Caring in uncertain circumstances, adapting responses
In the South Caucasus, the main goal of harm-reduction measures remains largely unmet and requires more efficient distribution of needle and syringe programs, methadone maintenance treatment, and psycho-social support services. There is a lack of political will in the region to accommodate such measures as well as strict prohibition laws and the active engagement of law enforcement agencies in preventing users from maintaining their anonymity when applying for treatment. Such obstacles prevent frontline workers from providing the necessary support, as they too are often restricted in their abilities to accommodate the immediate as well as the long-term needs of patients.
According to the coordinator of the MMT in Baku, the grey number of people who use illegal drugs in Azerbaijan is around 300,000. Specialists need to be better equipped to respond to the withdrawal and treatment needs of users. There is no monitoring or statistics available on COVID-19 related changes and to the best of our knowledge, no other research studies have been carried out in the country in regards to drug treatment and changes in drug consumption. Most users are given specific COVID information only if they voluntarily come for a consultation and learn about ways to avoid weakening the immune system. This is especially alarm-raising given that methamphetamine has become increasingly popular among people who inject heroin, potentially increasing vulnerability to coronavirus (UNODC 2020). The most frequently used technological means to reduce the number of face-to-face meetings were phone calls via doctors’ private mobile phones.
“We spend a lot more hours on the phone now. We are often forced to prescribe some medications over the phone due to distances and lack of services in remote regions […] These aren’t legal, stamped prescriptions, you understand. Someone on the other end of the line will just write down the name of the medication and show it at the local pharmacy” (P1).
Using their private mobile phones to continue to deliver necessary support is a form of commitment on the part of the doctors suggesting improvisation and quick response to the crisis without official guidelines. Many have not received any further support from the state in order to facilitate telemedicine, especially for patients without internet access, due to living in remote regions or digital illiteracy. However, referrals to in-patient and long-term treatment seemed at first less affected.
“To be honest, there haven’t seen significant changes. I mean we did not feel anything in particular. We have not stopped any healthcare services, methadone program, as well as inpatient and outpatient treatment have been open and work as usual” (P1).
The quote suggests that there was not any noticeable increase in new enrolment, at least at the earlier stages of the pandemic.
“Of course, we should consider that there are frequent users of pharmaceutical drugs, such as Tramadol and Lyrica, and that they might have a hard time getting those drugs due to reduced working hours of certain pharmacies or even complete shutdown. But these are all estimates, there are no statistical records” (P3).
“We have to cancel appointments with our patients, and some are seriously affected by this. Most are not able to attend online sessions and it is difficult for us not to feel responsible for their anxiety or increased alcohol intake” (P7).
Distrust and disobedience in safety measures
While the world is currently being governed by the minutest statistics and enumerations directly affecting social life and the ways the COVID-19 pandemic is being managed (Rhodes and Lancaster 2020), it is important to understand alternative realities and experiences. Denial of the existence of the virus in the initial stages and the state’s slow response in managing public safety measures caused a spike in infection and overloaded the hospitals with patients in critical condition. The state instructions fall short of providing adequate care services and guidelines for patients in need of drug treatment mainly due to the deliberate de-prioritization of these cohorts. A lack of statistical information and general disbelief contributes to scepticism also among professionals:
“To be honest, I personally do not care much for these safety measures. I do not wear a mask myself. As a doctor, I know that these masks are very inefficient against a virus” (P6).
Negligent attitude towards the virus among professionals themselves potentially affected work relationships and their views on safety measurements and patient needs:
“On a subjective level, I am rather unaffected by the panic around the virus, I think the majority should get it so that we form a collective immunity against it” (P4).
A lack of direct policy interventions and guidelines for frontline workers left many improvising and often not strictly following the safety measures:
“We check the temperature of patients when admitting them to a therapy session or long-term inpatient treatment, but that’s pretty much it. There is no mandatory testing, no other procedures to be sure if someone is COVID positive or not” (P1).
Working with families is more essential than before
The interviews were conducted in the form of focus groups with psychologists, social workers, doctor-narcologists (a term used in many post-Soviet countries to denominate drug treatment specialists), epidemiologists, nurses, and other personnel who continue to provide care and medical services to people who use drugs or seek treatment during the pandemic. Each focus group had three participants and two to three moderators (the principal investigator and one or two local coordinators).
“We are frequently put in a position to offer long consultations to parents. A big part of our work is with parents. They have to be informed because you know how it is, families are very involved here. We work not only with the patient, but also with the parents and our techniques can only work if their involvement is successful” (P4).
Given the poor service provision before the pandemic-related restrictions, we anticipated to find out more about personal challenges in the working conditions of the service personnel rather than improvements in policies or specific state instructions in response to the pandemic. Due to an increased need in providing health services through digital platforms and a recommended use of telemedicine where applicable, we also expected to find more about possible ways of digitizing certain care services. In this sense, further research is needed for a more nuanced analysis of the use of technological tools and the official SMS control system as an entanglement of different actors in creating adaptive drug services.
In contrast to state-funded treatment centers, several small-scale NGOs have managed to successfully distribute information sheets and sterile injection equipment to people who use drugs in the marginal areas of the city and the surrounding regions. Partly due to digital illiteracy and partly due to lack of trust in the safety rules, the Azerbaijani public seemed to not take the pandemic-related safety rules as seriously as would have been expected. Interviewed professionals believed that such a relaxed approach to safety and related precautions was a more humanist approach towards everyone who needed professional intervention.
“I mean you cannot just make patients wear their masks all the time, that simply does not work. A patient can freely come into my room, even sneeze or cough near me, and I have to hope this did not infect me” (P2).
As expected, many users continue to find drug delivery and may often disregard safety rules to reach the drugs, even if that means misusing the SMS-approval system (Medicalexpress 2020) to leave the house for pharmacy or grocery visits only.
“I mean, they have bigger problems, don’t they? Most are already ill with several conditions and this virus does not really scare them much” (P1).
Liaising between the capital and the regions
Due to the travel bans inside the country between the capital, surrounding municipalities, and the regions, many people who needed detoxification or consultation were not able to get help due to the fact that most city clinics, self-help fellowships, and NGOs all operate only in Baku. Nevertheless, the local principal investigator of the Global Fund Harm Reduction program reported successful cooperation between outreach workers and the local AIDS centre in Baku, which enabled the delivery of ART (antiretroviral-therapy) medications to patients in remote regions as the travel ban inside the country continued.
Workplace safety
According to the participants, the state provides masks for nurses and other staff members, however, most doctors prefer to buy their own masks themselves, mostly for better quality and choice. The staff is exposed to greater infection risk as patients refuse to wear masks or keep distance continuously. Patient-professional relationships are particularly important in psychotherapeutic counselling, especially due to reported increases in anxiety and alcohol intake, according to the personal observations of the professionals. Staff in detox clinics and inpatient care units face greater risks in comparison to professionals in psychiatric clinics as the latter has better technological equipment and more control over their work schedules. Online consultations have not proven their functionality with patients living outside of Baku, while physical safety measures seem to put more strain on patients with mental ill-health:
“Our patients feel really uncomfortable when we wear masks during face-to-face psychotherapy sessions. Some would quit coming to sessions and feel less connected and open than in regular times” (P3).
The situation seemed to frequently appear out of control in the national drug center. Patients were free to come to the centre at any time of the day and request a consultation or to be taken into immediate detoxification treatment, which often caused police involvement and long negotiations with the doctors about whether the patients could be taken in. Given that police officers often accompanied those arriving for treatment from remote regions of the country, law enforcement agencies were closely involved in registering users and monitoring treatment continuation for cases of termination or drug use and sales. Moreover, the isolation of patients with suspected COVID-19 cases as per mid-June was no longer feasible as the virus cases surged:
“We try to attend to everyone, but we are out of beds. Every day there are 30-40 new patients just waiting in line. I think most are simply bored. Some are of course unable to get their fix, so they come here to relax and ease withdrawal symptoms” (P1).
Conclusion and further implications
Policy conversations around drugs remain rare in Azerbaijan. Due to stigma and a punitive environment, many avoid open discussions even in a professional capacity. This partially contributed to the limitations of the study in terms of the depth of the collected data, leading to speculations that certain evidence such as death cases and related statistics as well as internal conflicts in service delivery and the neglect of patients remain hidden. Our data showed that to ensure safety and deliver drug services as well as hygiene-related services more efficiently to those in need, it is important that the government increase support of emergency stations in remote regions to reduce the number of COVID-positive patients commuting to Baku, to prevent the overload of city treatment centers, and to sustain safer working conditions for the professionals on the frontlines (see also EMCDDA 2020 for the suggestions in the EU region). Monitoring and testing should be made easily available for professionals to ensure workplace safety and prevent large outbreaks of the virus in treatment centers.[1]
References
Altice, F. L., Azbel, L., Stone, J., Brooks-Pollock, E., Smyrnov, P., Dvoriak, S., Taxman, F. S., El-Bassel, N., Martin, N. K., Booth, R., Stöver, H., Dolan, K., & Vickerman, P. (2016). The perfect storm: incarceration and the high-risk environment perpetuating transmission of HIV, hepatitis C virus, and tuberculosis in Eastern Europe and Central Asia. The Lancet, 388(10050), 1228–1248. https://doi.org/10.1016/S0140-6736(16)30856-X
Azbel, L., Wickersham, J. A., Wegman, M. P., Polonsky, M., Suleymanov, M., Ismayilov, R., Dvoryak, S., Rotberga, S., & Altice, F. L. (2015). Burden of substance use disorders, mental illness, and correlates of infectious diseases among soon-to-be released prisoners in Azerbaijan. Drug and Alcohol Dependence, 151, 68–75. https://doi.org/10.1016/j.drugalcdep.2015.02.034
Deilmizade, A., & Moghanibashi-Mansourieh, A. (2020). Challenges of providing COVID-19 prevention services to homeless people who use drugs in Iran. International Journal of Drug Policy, 102806. https://doi.org/10.1016/j.drugpo.2020.102806
del Pozo, B., & Beletsky, L. (2020). No “back to normal” after COVID-19 for our failed drug policies. International Journal of Drug Policy, 102901. https://doi.org/10.1016/j.drugpo.2020.102901
Dunlop, A., Lokuge, B., Masters, D., Sequeira, M., Saul, P., Dunlop, G., Ryan, J., Hall, M., Ezard, N., Haber, P., Lintzeris, N., & Maher, L. (2020). Challenges in maintaining treatment services for people who use drugs during the COVID-19 pandemic. Harm Reduction Journal, 17(1), 26. https://doi.org/10.1186/s12954-020-00370-7
Eurasian Harm Reduction Association. (2020). Harm reduction programmes during the COVID-19 crisis in Central and Eastern Europe and Central Asia (Issue May).
European Monitoring Centre for Drugs and Drug Addiction. (2020). Impact of COVID-19 on drug services and help-seeking in Europe: EMCDDA trendspotter briefing. May.
Medicalexpress.com. (n.d.). Azerbaijan reinstates strict lockdown as virus cases surge. Retrieved July 1, 2020, from https://medicalxpress.com/news/2020-06-azerbaijan-reinstates-strict-lockdown-virus.html
Rhodes, T., & Lancaster, K. (2020). Mathematical models as public troubles in COVID-19 infection control : following the numbers. Health Sociology Review, 0(0), 1–18. https://doi.org/10.1080/14461242.2020.1764376
Stöver, H. (2009). South Caucasus anti-drug (SCAD) programme (Phase V). https://doi.org/10.2174/138920312803582960
Sultan, A. (2019). Recovering assemblages: Unfolding social and material practices of drug recovery in youth [Doctoral dissertation, Goethe University Frankfurt]. Library for Social Sciences and Psychology.
United Nations Office on Drugs and Crime. (2020). World Drug Report. www.unodc.org/wdr2020
World Health Organization. (2020). Health Workers. https://www.who.int/emergencies/diseases/novel-coronavirus-2019/technical-guidance/health-workers
[1] We would like to thank our participants for their collaboration in helping us to collect data amidst intense work conditions.
