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In mid-March, as the Covid-19 pandemic was accelerating, Shantae Owens found a man unconscious in a public bathroom in Tompkins Square Park, in New York’s East Village. Owens wasn’t surprised at his discovery. He was on street outreach distributing naloxone, which helps reverse opioid overdoses, as well as syringes, condoms, and other health supplies. He administered naloxone and called 911. The ambulance took longer to arrive than usual.

Owens is an outreach worker with the Lower East Side Harm Reduction Center, which has temporarily stopped doing outreach due to Covid-19-related safety concerns. But he still covers the parks, public restrooms, and drug houses of the South Bronx, Washington Heights, and Lower Manhattan as a volunteer with VOCAL-NY, a grassroots organization that grew out of the AIDS epidemic and is staying open during the lockdown. Many harm reduction programs are still running as essential services, though others, such as those that operate out of county health departments, like Michigan’s, are now largely closed because of Covid-19. Owens is concerned about what the lockdown will mean for drug users—in particular, for people who use opioids and are at high risk of fatal overdose. “We fear that overdose is going to rise,” Owens told me, “because there’s not enough services. We’ve already lost so many people to the overdose crisis.”

Around the country, organizations that work to reduce drug-related harms such as overdose, HIV, and hepatitis C are now facing yet another devastating virus. And for active drug users, people in drug treatment, and people without stable housing, business closures and physical distancing mandates are causing a cascade of economic and practical difficulties that compound health dangers. “I worry for my community,” said Kelly Culbert, who works at NYHRE, an East Harlem harm reduction center that has closed temporarily. “They’re scared. They have very little access to equipment [for safer drug use]. And everything has become more problematic—from the ways people were making their money to locating a dealer and that person having an adequate supply. It’s all become riskier, less available.”

Among the harms that advocates like Culbert fear most are a spike in overdoses, increased syringe sharing, and a choice between self-isolation and excruciating drug withdrawal. There are already reports from across the country of increased overdose rates.

Project SAFE works with women and queer people who use drugs in Philadelphia’s Kensington neighborhood, delivering harm reduction supplies and offering a place to take a shower or a nap. Many program participants are precariously housed and stay up all night to avoid being assaulted; they need a place to help them escape the cycle of exhaustion.

Board member Jeanette Bowles worries that overdose rates will rise because of fluctuations in the drug market, economic contraction, and self-isolation. “Your ability to maintain economic stability affects overdose risk,” she said. “And we’ve been telling people for years that they should never use alone—that’s one of the biggest risk factors for overdose—but now we’re telling them to stay home.”

The national “Never Use Alone” hotline offers an operator who will stay on the line while you use, calling 911 if you become unresponsive. But people are wary about disclosing their drug use and address to a stranger, and many of Project SAFE’s participants don’t have stable access to a phone. It’s hard to hang onto one when you’re homeless.

What’s more, many of Project SAFE’s participants are sex workers—and sex work is another economic area affected by the recent contraction. “Business is really slow,” said Lulu Duffy-Tumasz, delivery services coordinator for Project SAFE. “People are hustling even harder, but not making enough money for drugs. We’ve gotten more requests for pepper spray, and we’ve been preparing for people who are having to work in situations they normally wouldn’t, because of scarcity.”

Meanwhile, local harm reduction sites may be the only places left where homeless people can take recommended measures for protecting themselves against Covid-19. “Hearing all the messages of ‘stay at home, wash your hands’—for people who don’t have homes to stay in, that hurts,” said Alice Bell, the overdose prevention project coordinator at Prevention Point Pittsburgh. “What are they supposed to do with that information? But they’re very relieved to know that Prevention Point is still open.”

Even with drop-in centers closed, harm reduction programs are still letting people in to use the restroom, one by one. The restrooms of some harm reduction centers also serve as de facto safe injection sites, with staff knocking regularly to check on users, naloxone on hand. And for people who use cocaine, methamphetamine, and other non-opioid drugs, organizations provide clean smoking equipment, to reduce sharing—especially important during a pandemic of respiratory illness.

Staff at these facilities are accustomed to chaos and uncertainty, but they aren’t used to feeling that their own lives are at risk, and that they don’t have the means to keep themselves safe. “It’s very easy to forget that we’re front-liners,” said Jose Benetiz, executive director of Prevention Point Philadelphia. “The services we’re providing are essential services to keep people safe. We’d love to have enough protective equipment not just for staff, but to be able to give gloves and masks to people on the street so they can protect themselves.”

When I spoke to Arash Diba, VOCAL-NY’s head of harm reduction, his voice was sharp with anxiety. “We are literally wearing our last masks now,” he said. At VOCAL-NY, Prevention Point, and other harm reduction programs, essential staff members have been divided into “pods” so that the organizations won’t have to shut down entirely if there’s a Covid-19 infection or exposure.

People on medication-assisted treatment, or MAT, face a special set of difficulties. Because of concerns about abuse or diversion of medication, methadone patients are generally required to appear in person at a clinic for their daily, supervised doses. This makes physical distancing and self-isolation almost impossible for methadone patients and clinic staff. New regulations issued in response to Covid-19 allow for patients to receive two to four weeks’ worth of methadone at a time. But clinics have been left to sort out the details themselves, and to make their own decisions about who can have take-home doses.

Some of New York City’s 30,000 methadone patients have received two weeks’ worth of medication, but many others have simply been put on a staggered schedule, still coming in three times a week. As a result of physical distancing guidelines, patients have to wait in line outside, often for long periods, regardless of the weather. Many travel to the clinic by bus or by train, potentially exposing them to the novel coronavirus. If they have to self-isolate or self-quarantine, they’ll face the prospect of agonizing drug withdrawal, whose symptoms can resemble those of Covid-19—from headaches and body aches to runny nose and fever.

Jasmine Budnella, VOCAL-NY’s drug policy coordinator, told me a dramatic story illustrating the dangerous collision of MAT restrictions and public health imperatives. In March, a homeless man tested positive for Covid-19 and was assigned a room in a designated Brooklyn isolation shelter. When he entered, he had enough methadone with him to last five days. Budnella and others struggled to find a way for him to have his next doses delivered in time, but couldn’t manage it. As a result, he broke quarantine to take the subway to his clinic in Manhattan. This public health failure prompted the city to develop a system to deliver methadone to patients in isolation shelters. It launched this week, after several delays.

Meanwhile, there’s an urgent need to help people start MAT while physically distancing. With their usual sources of income drying up, many active users can no longer get the drugs they need to keep them from going into withdrawal, which is in turn leading to increased demand for entry into MAT programs. Regulations have been loosened to allow for the prescription of buprenorphine (a less strictly controlled form of MAT) by telephone; activists are calling for the same changes for methadone programs.

Like the loosening of restrictions on naloxone access in response to the overdose epidemic, these sudden changes are a tantalizing reminder that rules are more flexible than they may appear. “Things that seemed like insurmountable obstacles a few weeks ago suddenly don’t seem so hard to do, like hand-washing stations in the homeless encampment, or finding places for people to live,” Bell told me. Certain categories of prisoners are being released early. Many cities, including New Orleans, Los Angeles, San Francisco, and Philadelphia, have begun renting hotel rooms for homeless people.

VOCAL-NY and other advocacy groups have been pushing hard for New York to follow suit and secure 30,000 hotel rooms for the city’s homeless. On April 11, Mayor Bill de Blasio announced that the city would relocate 6,000 homeless New Yorkers to hotels. It will be important that these sites provide for MAT and overdose prevention; in New York City, overdose is the leading cause of death among the homeless.

These are temporary improvements made in response to an emergency. Harm reduction advocates plan to fight to make many of them permanent. But for Budnella, such small steps forward are not enough to address the “wave of death” caused by failed drug policies. “We need to decriminalize drugs,” she said, “and bring people to the center of this work.”