Effects of COVID-19 on Community Programs for Justice-involved Adults with Behavioral Health Disorders

by Dr. Allison Robertson, Associate Professor, Services Effectiveness Research Program, Department of Psychiatry and Behavioral Sciences, Duke University School of Medicine

Much important attention is focusing on how the COVID-19 pandemic is gravely affecting people who are incarcerated in US jails and prisons, a crisis that is worsening daily. There are also very serious concerns about justice-involved people who are living in the community during the pandemic, and are at particularly high risk for bad outcomes both directly and indirectly related to the disease.

People with behavioral health disorders, are, in normal times and now more than ever, especially vulnerable to a range of bad outcomes—arrest and incarceration, being victimized in the community, drug overdoses, and their basic needs going unmet.  There are a range of programs that provide community-based services in particular to justice-involved adults with mental illness and/or substance use disorders.  Those programs and the people they serve are struggling during this pandemic, with major disruption in service provision and access for clients.

Law Enforcement Assisted Diversion (LEAD) is a pre-arrest jail diversion program that connects people who use drugs to a range of treatment and social services in the community in lieu of arrest for drug-related and other low-level criminal offending. The LEAD model, which is based in an active partnership between law enforcement and service providers, takes a harm-reduction approach, with strong community outreach to clients and meeting them “where they are”, whether it is only to provide harm reduction resources like naloxone and syringe exchange, or to connect them to treatment and social services, if desired.

North Carolina has been an early adopter of the LEAD model, with several active programs around the state. Under normal circumstances, LEAD and similar community-based programs are fragile, with a scarcity of funding, a difficult to reach population, and very often, an entirely insufficient service system, especially for those who are uninsured. COVID-19 is having real-time impacts on LEAD programs, and is sure to have longer-term consequences for their clients, as well.

Following are reports from some of our research team’s law enforcement and service partners that have active LEAD programs in NC about ways in which COVID-19 is affecting their client population:

One law enforcement leader reported seeing increases in overdose deaths since pandemic lockdowns were instituted. If overdose deaths are indeed on a pandemic-related rise, possible   reasons for that could be:

  • people using drugs alone due to social distancing requirements (in normal times, a central harm reduction message is “don’t use drugs alone!”)
  • disruptions in the drug supply, e.g., if a person’s regular dealer/supply has become unavailable, they may switch to a new dealer, whose supply may put the individual at higher risk for fentanyl exposure
  • disrupted access to syringe exchange services given exchange programs have closed their brick and mortar sites and gone to mobile distribution only; some people don’t have the wherewithal to adapt to that and consequently lose access, which could increase acute mortality risk due to overdose, and increase HIV/Hepititis C transmission risk and associated longer-term morbidity and mortality associated with those diseases

Some programs are seeing both benefits and adverse effects in the switch from in-person to tele-therapy for program clients.

  • Benefits: Some clients are reportedly becoming better engaged in treatment with long-standing barriers of poor transportation and stigma concerns eliminated in the tele-therapy context, and some strongly prefer the convenience and comfort of engaging by video in their own space rather than visiting a treatment clinic.
  • Adverse effects: For clients who are unable to engage in tele-therapy, they have potentially lost all access to behavioral health treatment, and there is a real concern that they will deteriorate and/or not re-engage in treatment again once service provision returns to normal.

Field workers, including peer support, are only working with clients by phone; those without phone access are largely cut off from support services.

These and other COVID-related disruptions to programming could have serious and even deadly consequences for LEAD clients and other people with behavioral health disorders receiving services from similar community-based programs.  Police officers are reportedly making fewer arrests for low-level crimes and drug use, which reduces the likelihood of people who use drugs will be incarcerated, but may also have not yet understood effects of increasing risk for overdose if people are using drugs, without interruption, in deep isolation. Concerns about increased risk for violent victimization is a particular concern for this population of people who use drugs, both in the community by unknown perpetrators and also intimate partner violence.

These are surely just some of the real-time effects of COVID-19 that are being felt now by LEAD programs and their clients. The longer term consequences for community-based diversion programs is not yet known. Community outreach efforts should be maintained, as possible, and strong communication between law enforcement and treatment program stakeholders is crucial during this time when their program clients are uniquely vulnerable.