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In late March, North Carolina Governor Roy Cooper directed businesses to close because of the coronavirus pandemic—only those deemed essential could remain open. For many, nothing is more essential than the syringe exchange at the North Carolina chapter of the Urban Survivors Union (NCUSU), a harm-reduction group run by and for people who use drugs.

Louise Vincent, the executive director of the NCUSU, said their drop-in center is doing its best to adhere to public health guidelines; they have, for example, installed a plexiglass barrier and a Dutch door to help them maintain distance from their clients. This has allowed them to keep providing clean needles and helping clients stick with the treatment programs. The center has also moved its support groups online and is running a virtual “advocacy academy” to enable people to press lawmakers for better access to treatment and decriminalization of drugs.

“We’re busier than we’ve ever been,” Vincent told me.

Still, even with the work of groups like the NCUSU, the pandemic and lockdowns will increase the risks of opioid deaths. Counties in Arkansas, Florida, New York, and Ohio have already reported spikes in opioid overdoses.

“I’m truly worried about what’s going to happen to people,” said Vincent. “I really worry in this crisis that we are going to harm people that are already very vulnerable and struggling.”

Before Covid-19, the opioid epidemic was arguably the country’s most urgent public health scourge, killing 46,802 people in 2018. Now, advocates for people who use drugs fear that the stay-at-home orders, along with the financial havoc spurred by surging unemployment, could cut people off from medication-assisted treatment (MAT), which they need to stay stable and stave off the horrific illness that accompanies withdrawal. It’s not just that physical isolation could lead to social isolation; the pandemic has also disrupted the transnational drug markets for opioids, boosting street prices and potentially cutting many off from their usual supplies of opioids. Harm-reduction groups have urged people to stock up on drugs (as well as on methadone or buprenorphine) in case their supply dries up.

Whether they are addicted to prescription painkillers or black-tar heroin, many people who use opioids struggled to access treatment even before the pandemic. The methadone treatment protocol typically required patients to get their doses through daily supervised clinic visits, which often required waiting on long lines. Similarly, another popular treatment drug, buprenorphine, required in-person visits with a certified medical practitioner.

But in the era of social distancing, federal health authorities have made some emergency reforms that many hope will endure once the pandemic ends. Under new guidelines on the distribution of MAT drugs issued by the Substance Abuse and Mental Health Services Administration (SAMHSA), people can get up to 28 days of doses in one batch (or two weeks if they are deemed “less stable”). The guidelines also allow doctors and other licensed health care practitioners to evaluate patients through a Telehealth appointment.

Yet local media and advocates have reported that the new federal guidelines have sometimes been flouted. In late March, the New York Daily News reported that patients at a crowded Brooklyn methadone clinic were initially being denied take-home medication. A month later, long lines appeared at a methadone clinic in San Antonio. (Both facilities later claimed they were adjusting to the new policies.) According to STAT News, the National Alliance for Medicated Assisted Recovery has received reports from several states, including Massachusetts and Florida, that clinics have continued to make people pick up doses in person or attend group counseling sessions—even patients who are immunocompromised or diagnosed with Covid-19.

More than a month into the stay-at-home order, Vincent said that in her community in Greensboro, N.C., there were still lines at methadone clinics, and that people had to attend counseling sessions in person and could receive only a supply for a few days—not the two week’s worth that the new guidelines allow: “Now you’re just lined up down the street, six feet apart…. Why are we so absolutely resistant [to the new guidelines]?… I think one of the reasons we don’t hear more about it is because people are so beaten down by these clinics…. You’re in an environment where you clearly don’t matter.”

The pandemic is likely to exacerbate anxiety, depression, and intimate-partner abuse, all of which could intersect with barriers to treatment for people with opioid use disorders. Rehabilitation programs have shut down and had to offer counseling via videolink. Many users face the stigma of addiction in solitude, and the risk of overdoses increases when the nearest inpatient detox facility might be closed or now a several-hour drive away. Moreover, for people with diseases associated with opioid use, like Hepatitis C or HIV, access to health care might decline as distressed hospital systems absorb a surge in coronavirus patients.

“I’m sure that we are going to see increased overdose,” Vincent said. “Look, people are sheltering in their homes, domestic violence has gone up, people are stressed out, bored. Yeah, we’re going to see more overdoses.… Just the pure stress of it. And then [Narcotics Anonymous] and [Alcoholics Anonymous] not operating, and treatment centers not seeing people, and methadone clinics not raising people’s doses. And everything standing still in a world that’s not standing still.”

Harm-reduction advocates also worry that fewer people will take advantage of their services. Sarah Ziegenhorn, executive director of Iowa Harm Reduction Coalition, said in an e-mail, “We’ve also seen a decreased number of clients, and we are hearing this from every program across the country. Fewer clients coming into our drop-in center and to our outreach sites means that people are going without sterile injection supplies.”

Then there is the issue of clients’ not taking the risk of Covid-19 seriously. Among the clients she works with, Ziegenhorn said, “most laugh at me when I ask them to keep a little bit of distance between other people and themselves.… A lot of responses are along the lines of, ‘My life is too stressful to need to think about this.’”

Harm-reduction advocates hope the relaxed federal rules for medication-assisted treatment will lead to broader reforms. Building on the SAMHSA guidelines, more than a dozen advocacy organizations, including Drug Policy Alliance and National Council for Behavioral Health, sent a letter to state and local government recommending additional safeguards to protect the health of people who use opioids, including giving all patients take-home privileges for MAT prescriptions “to the maximum extent possible”; authorizing facilities like pharmacies and medical-aid vans to provide take-home medication; and deploying federal and state Medicaid funds to pay for take-home medications that are not covered by insurance. The letter also urged authorities to allow treatment and needle-exchange facilities to refer people for Covid-19 testing, effectively turning harm-reduction specialists into frontline health care workers.

But it remains to be seen whether the relaxation of MAT rules will lead to broader systemic reforms. People who use opioids continue to face hostility from law enforcement: In Marion County, Ind., near Indianapolis, for instance, police have announced that they would stop administering the overdose-reversal drug Narcan to overdose victims—potentially leaving people to die—for fear that they might cough or sneeze and infect an officer with Covid-19.

Aspects of harm reduction have started to enter the public conversation and even driven incremental reforms like the decriminalization of marijuana. But basic harm-reduction facilities like needle exchanges still often operate in a quasi-legal gray zone, as policy-makers claim such programs encourage drug use.

Although needle exchanges are legal in Greensboro, Vincent said that stigma still surrounds the NCUSU’s grassroots syringe services, because authorities “just can’t wrap their head around people who use drugs wanting to engage with their community. I guess it flies in the fact of everything they say about people that use drugs—that we actually care about our community, that we actually care about our health, that we actually care about one another, that there is community resilience.”

The campaign to establish “safe consumption sites” has met even more resistance. Local governments have bristled at providing people a clean setting for drug use. In general, opioid use remains heavily criminalized and subject to draconian policies, such as federal and state drug-induced homicide laws, which allow someone to be charged with homicide if they manufacture, sell, or provide drugs that later cause the someone’s death.

The focus on criminalization stems in part from concerns about fentanyl, a powerful opioid that is seen as particularly dangerous, explained Daniel Raymond, the deputy director of planning and policy with the New York City–based Harm Reduction Coalition. “You have state after state passing laws,” he said, “including states that had gone through sentencing reform for other drugs in recent memory—saying, ‘Oh, but fentanyl’s too dangerous so we need to treat it like the bad old drugs of the ’80s and actually increase penalties.’”

Despite the political inertia, one area where there has been a political shift in recent years has been the expanded use of naloxone, an effective overdose-reversal drug often known by the brand name Narcan. As local governments have seen spikes in overdoses during the pandemic, social service organizations have worked to meet the growing need for Narcan by sending mailers and doing online trainings for administering the medication.

Harm Reduction Ohio has distributed just over 1,900 naloxone kits in March—a record—and is also supplying Narcan to supplement take-home prescriptions of methadone.

“I hope [the Narcan] goes into the hands of people who are going to use it,” said Billy McCall, advocacy director of Harm Reduction Ohio’s syringe program, who recently left a halfway house following a drug-related prison sentence of eight months. He noted that opioid use could intensify, since the price of methamphetamine has soared in recent weeks because of disruptions in the supply chain for illicit drugs.

On a personal level, he said, “I know a few people that have overdosed in the last few weeks that have never overdosed in their life,” because they are so distressed by the Covid-19 crisis, “and the depression that comes with all this, and the void of not working, the financial stress, and just…   everything.”

Nonetheless, McCall is heartened by the recent changes in the federal guidelines for distributing medication-assisted treatment. “I think that for so long, people have been trying to get this changed,” he said, “and there’s all this red tape…. And what it all came down to with coronavirus is the flick of a pen, and they were changed.”