Background
The Covid-19 pandemic impeded the delivery of addiction support services to this high-risk group as existing healthcare models were dramatically altered or abolished. The impact of the pandemic negatively affected addiction recovery, with adverse health outcomes and drug-related mortality seen to increase, in turn impacting the wellbeing of practitioners already under pressure.1 A 2022 study explored the impact that the pandemic had on the wellbeing of Irish healthcare professionals supporting clients with addiction.2
Method
In total, 15 professionals working in homelessness, addiction, public health, and emergency medicine who worked with people who actively take drugs were recruited to take part in the qualitative study using semi-structured interviews. To be included in the study, participants must also have experienced a drug-related death of a client (excluding bereavements within 3 months of the survey) and be in an active healthcare role. Participants were recruited nationwide.
Data analysis
Transcribed data were analysed using Braun and Clarke’s updated six-step process, where data are analysed using reflexive thematic analysis.3 This technique uses a repetitive sequential process of data familiarisation, coding, initial themes generation, reviewing themes, defining and naming themes, and writing up. Qualitative analysis software NVivo was used in the process. From a quality control perspective, Dodgson’s recommendations4 to avoid author influence of data interpretation were maintained throughout the qualitative research process.
Results
Four core themes were generated from the analysis: shift in priority; being left behind; managing a death; and anxious environment. Associated subthemes provided further information and context.
Shift in priority
Priorities that were typically client-centric shifted towards Covid-19 safeguarding and infection controls. Participants expressed feeling unprepared, confused, anxious, occupationally stressed, and internally conflicted as the new priorities challenged their existing professional values:
In addiction you’ve got to be flexible. Especially with Covid, it can’t just be about the client now. I have to consider all the people in the building, my colleagues, my staff, myself, even my own family.
While the importance of safeguarding was understood, the participants feared for the lack of services for their clients:
...in the last six months, I don’t know if I’ve had one patient who was treated…
The subtheme ‘high threshold’ was identified as the ease of accessing services was reduced, creating a barrier for clients:
The ideal is to have specialist low threshold services, no appointments, the least amount of administrative barriers. And all of that is the total opposite of what we’re told to do as a service provider to keep the service safe now [during the Covid-19 pandemic].
Covid-19 protocols undermined the foundation of addiction services and reduced the number of services remaining in operation because of closures. Participants reported stress and associated emotions with the loss of control over client care.
Being left behind
Three subthemes were identified: ‘lost in transition’, ‘digital divide’, and ‘new relationship dynamics’. Addiction continued as a major public health concern during the pandemic with those experiencing addiction becoming more vulnerable than before:
Addiction doesn’t go away, and the lockdown has pushed more people to risky behaviours ... I feel [the pandemic] is going to leave more people behind than were being left behind before.
Participants were left feeling uncertain, experiencing loss of control and feelings of helplessness to provide services required by their clients:
That is my biggest fear right now ... I don’t feel I can do anything for them right now, even as somebody with a lot of experience. I feel a little bit helpless in this situation.
Clients’ recovery noticeably worsened with increasing wait times leading to ‘slips’, dropping out of contact, and getting ‘lost in transition’ during their recovery period. It left the participants feeling demoralised or with low morale:
If you’re in recovery and you were struggling beforehand, you know it’s too much to handle for people on their own.
One participant declared:
I can’t do that for six months ... It’s really disheartening as a worker to know that a service might not be available for someone when you know they’re ready now.
The introduction of virtual communication with clients resulted in many barriers from lack of infrastructure, knowledge, access, and tools, and abolished the sense of security and safety that in-person private sessions provided. One participant recalled:
The front doors of services were shut, and not all my patients and clients have smartphones and can’t do video counselling. There is a digital divide.
Another pointed out:
…some don’t like speaking over the phone, because they might have a mental health fixation on the fact that someone is going to hear something about their business. On the phone, how are you supposed to make someone feel safe?
The pandemic changed relationship dynamics between the participants and their clients, with connections becoming strained, leaving clients feeling abandoned when staff were redeployed due to the pandemic:
It has a huge impact on staff wellbeing … We have such an amazing relationship with the participants … and they’ve built such trusting professional relationships … But all our clients may not understand the fact that I’ve been redeployed and I’m unavailable...
Managing a death
In the event of a client’s death, participants reported feelings of guilt, blame, personal responsibility, and self-questioning for these ‘preventable deaths’.
There’s an unbelievable guilt. I always feel it’s my fault if one of my patients dies.
Participants’ strong emotional investment accompanied with Covid-19 protocols and administrational demands following the death of a client left little time to process the death:
...and they’re left with nowhere to process that emotion, or that grief. They can’t attend the funeral ... If I don’t go to funerals, I always expect them [the client] to come back. It’s me closing that relationship with them…
Certain guidelines were loosened due to Covid-19 protocols to cater for the needs of clients, leaving participants feeling exposed and anxious about legal outcomes should a death occur:
You might give them a little bit more takeaways so that they don’t have to go to the chemist every day to get their methadone. Those sort of loosening of the guidelines means that everyone is a little bit more exposed.
Anxious environment
Anxiety was highly prevalent throughout the interviews, suggesting Covid-19 created an anxious environment for the participants to work in. Between self-monitoring for Covid-19, questioning their own mental health and fitness to work, and the occupational stress the pandemic created, all corners of their lives were affected. One participant recalled:
It is so impactful at all levels ... Never, ever, ever have I found it so difficult to separate work from home.
Discussion
Areas of concern for future service delivery and opportunities to future-proof services as society moves towards hybrid models of working were highlighted. The rigid protocols around service provision and the digital divide created due to public health measures pushed this high-risk group further away, significantly impacting practitioners’ occupational wellbeing. Feelings of anxiety, helplessness, and concern for mortality of their clients prevailed. Nonetheless, the participants continued to support this group in the most difficult of circumstances.
1 Nikmanesh Z, Baluchi MH and Pirasteh Motlagh AA (2017) The role of self-efficacy beliefs and social support on prediction of addiction relapse. Int J High Risk Behav Addict, 6(1): e21209.
2 O’Callaghan D and Lambert S (2022) The impact of COVID-19 on health care professionals who are exposed to drug-related deaths while supporting clients experiencing addiction. J Subst Abuse Treat, Early online. https://www.drugsandalcohol.ie/35544/
3 Braun V and Clarke V (2019) Reflecting on reflexive thematic analysis. Qual Res Sport Exerc Health, 11(4): 589–597.
4 Dodgson JE (2019) Reflexivity in qualitative research. J Hum Lact, 35(2): 220–222.
