Highlights from an assessment of the effect of COVID-19 pandemic on the provision of drug treatment services provided by Turning Point Treatment Centre, Saint Lucia

Highlights from an assessment of the effect of COVID-19 pandemic on the provision of drug treatment services provided by Turning Point Treatment Centre, Saint Lucia

Conducted for PAHO  

Researched and written by Marcus Day

 1 December 2020

 Executive Summary

A review of Turning Point Drug and Alcohol Treatment Centres observance of International Standards for the treatment of drug use disorders, revealed that Turning Point was largely in compliance to the Standards. As a nation, Saint Lucia fell short in two areas:  the lack of a comprehensive national drug and alcohol treatment programme consisting of a network of community programmes feeding up into residential treatment and onward to aftercare. The other is a legislative framework that codifies standards and licensing requirements for individuals and institutions providing drug treatment services.

The report that follows provides the support and justifications for implementing a phased in, comprehensive, national drug and alcohol treatment programme with codified standards over the next five years.

Immediately and as a precursor, the Ministry of Heath should adopt the COPOLAD training curriculum / course offerings on drug and alcohol studies and seek innovative ways to provide training virtually. There exists at Turning Point a certified Master Trainer in the Copolad OAS/EU funded training curriculum. Their services are available to begin this important initial phase of cultivating the human resources needed to phase in the network of services listed below.

A comprehensive national network starts with community-based outreach utilizing non-specialized settings like local Wellness Centres or Community Centres where services may be provided and outreach teams based. Outpatient psychosocial services in the form of individual and group sessions would be on offer and a peripatetic social worker available to assist with other services.

Inpatient psychosocial treatment is already available at Turning Point. In a comprehensive programme, individuals could be identified at the community level and as required referred to Turning Point or residential treatment. This residential care could include medically assisted alcohol detoxification. This is provided in conjunction with the Owen King EU Hospital. For some who move through the programme, there may be a need for long-term residential community-based care and recovery-support services and transitional housing; each an important component.

The National Mental Wellness Centre currently provides residential treatment for psychiatric / drug co-morbidities. Patients stabilized and deemed ready to return to the community often need group housing to maintain stability and physical health. The community programme would also serve people with concurring drug and psychiatric issues.

To be accessible and utilized, a comprehensive national drug and alcohol treatment programme would:

• be free and available in both urban and rural settings
• be accessible, with a wide range of opening hours appropriate to the population being served.
• be low threshold with minimum barriers that facilitate access to appropriate treatment services
• offer treatment for substance use disorders that includes trauma as an antecedent to substance use.
• offer basic first aid and be available as an immunization site as needed
• provide social support and protection, as well as general medical care
• offer a wide variety of high-quality interventions at various levels to meet the needs of a diverse population of substance users.
• be welcoming
• offer partnership opportunities with civil society and community- based organizations to provide an effective comprehensive drug treatment programme across the continuum.

 Background

Saint Lucia, is an island state in the Caribbean Sea. It is the second largest of the Windward group in the Lesser Antilles and is located about 24 miles (39 km) south of Martinique and some 21 miles (34 km) northeast of Saint Vincent.  Since the 1980s Saint Lucia has been increasingly used for the trans-shipment of cocaine to Martinique and onward to the more lucrative European markets.  Marijuana, which is produced in Saint Lucia is both used locally and exported in increasing quantities to Martinique.

The excessive use of these substances causes harm to both individuals, the family and the community. The disinhibition related to substance use has been associated with physical and mental health problems and greater risks of acquiring viral and bacteriological illnesses through close associations, sharing beverages or drugs and unprotected sex.

While the overuse of crack cocaine and alcohol presents the main challenge for treatment, there is evidence of the use of other substances. These include the non-prescription use of other pharmaceuticals or the use of inhalants such as thinners, glue, and gasoline, as reported in the OAS/CICAD school surveys[1]. Despite that evidence, the only three substances that residents at Turning Point have reported using are cannabis, crack cocaine and alcohol. The existing legislation addressing drugs and alcohol largely focused on a punitive and criminal justice response to illicit drug and a regulatory and taxation framework for alcohol, with little attention to the health and treatment needs of these populations.

COVID-19 is an illness caused by a novel corona virus that may cause respiratory infection and other complications. The World Health Organisation (WHO) was informed of an outbreak of this novel corona virus on 31 Dec 2019. Ten (10) weeks later, the disease which by then was named COVID-19 became a global health emergency and a pandemic. By mid-March there were more than 118 000 cases reported in 114 countries, and 4291 deaths recorded.[2]

Saint Lucia reported its first COVID-19 case on 13 March, 2020. Schools were closed on the 19^th of March and the borders closed on 23 March 2020. Liquor sales were suspended on the 29^th of March until the 14^th April. A phased reopening began in mid- June, 2020. Because of good management, the spread of COVID-19 was curtailed stalled, and there was a general belief that the country had been spared the worse. Cases held steady at 26 cases, and no deaths until mid- October when cases began to rise and by the end of the next month, 171 new cases were detected and 2 COVID-19 deaths reported.

The introduction of COVID-19 into Saint Lucia has stimulated major adjustments to health care in Saint Lucia. Addressing the health needs of the community of people who use drugs, alcohol and/or other vulnerable populations at the community level allows for a far easier implementation of epidemic mitigation strategies when it is necessary.  Other than the public health messaging generated by the Ministry of Health, there is no specialized messaging or outreach to the homeless, vulnerable, drug and alcohol using populations of our urban communities.

In Saint Lucia as elsewhere COVID-19 disproportionately affects poor people living in congested, overcrowded housing often with inadequate sanitation.

Services for people who use drugs and alcohol are essential services and the Ministry of Health must ensure that existing services remain available even when other services are reduced or closed due to COVID-19. Public health funding must include the maintenance, delivery and expansion of drug and alcohol prevention services especially in times of crisis when substance use as a coping mechanism may be increased. The provision of universal health care will remove financial barriers to access and increase utilization especially for the most vulnerable.

Purpose and Scope of the Assessment

The immediate purpose of this assessment is to determine the impact of COVID-19 on service uptake at Turning Point drug treatment programme. This was accomplished with a brief comparative analysis of the years 2013 – 2019.  For the years 2013-2019, annual admission rates range from 54-86. In 2020 (January to September), the facility has only recorded 23 admissions, less than a half of previous annual rates. This has raised questions and concerns about the impact of the COVID-19 pandemic on the access to treatment.

In the process of conducting the assessment, the investigator also:

Set out to determine the level of demand for drug treatment in Saint Lucia. This information is available to use in designing services and treatment options required to meet the needs of people who use drugs during the pandemic and beyond. The assessment set out to identify the substance using populations of Saint Lucia, ascertain what substances are they using, how they use these substances and the impact the COVID-19 pandemic is having on available treatment options.

Other overlapping areas of investigation included:

• Determine the needs and expectations for treatment services in Saint Lucia, during the COVID-19 pandemic and beyond;
• Identifying the barriers to the utilisation and access of the treatment programmes in Saint Lucia;
• Assessing the vulnerabilities of people who use drugs and alcohol in Saint Lucia to COVID-19 and other communicable and non-communicable diseases of public health interest.
• Determine how compliant Saint Lucian legislation and service implementation is to international standards of care for “detoxification, rehabilitation, and drug addiction centres” and determine how well the treatment services in Saint Lucia meets those standards, and
• Conduct a review of relevant legislation and policies related to the management of persons with substance use disorder and the treatment of the disease.

Investigator’s COVID-19 mitigation strategy

COVID-19 is of growing concern in Saint Lucia. In the month that this assessment was undertaken, there were over 200 new cases reported with the figure increasing daily. The COVID-19 epidemic in Saint Lucia has transitioned from one originating from travellers arriving from abroad to one that is now characterised by community spread.

The investigator took the following actions to mitigate the risks associated with the current COVID-19 pandemic. Meetings were conducted electronically using a variety of platforms commonly used. These included Zoom, Facebook/Facebook Messenger and WhatsApp.

Email and Facebook Messenger was used to pose questions to various government stakeholders to clarify or augment data available from the desk review. Critical to success was remaining flexible given the extenuating circumstances brought on by COVID-19.

Methodology and process of conducting a virtual assessment

This assessment of the drug and alcohol scene in Saint Lucia was constructed from available data sets from previously conducted research and inputs from key informants. Available sources of information on drug use in Saint Lucia were assembled and an overview of the drug scene in Saint Lucia was constructed from this data. No affected persons, no people who use drugs were interviewed for this assessment due to ethical limitations.

As the headquarters of the Caribbean Drug and Alcohol Research Institute, Saint Lucia benefited from a number of investigations of people who use drugs. These included:

• 2002 Behavioural survey of people who smoke crack in urban Castries
• 2004 behavioural and sero-prevalence study (BSS) of people who smoke crack in urban Castries
• 2007 behavioural and sero-prevalence study (BSS) of people who smoke crack in urban Castries
• 2010 screening for TB at the Bordelaise Correctional Facility with Dr. Cleophas d’Auvergne, Senior Medical Officer_ Infectious Diseases
• 2012 unpublished data set of 110 interviews with cannabis sellers in the North of Saint Lucia,
• 2012 data tables from a study of gangs and initiators of violence in Saint Lucia
• 2018 interviews with forty people who smoked crack and sold sex in urban Castries as part of a larger survey of male and female sex workers in Saint Lucia.

The 2007 BSS had 206 participants and included a number of indicators on access and utilization of health care by homeless people who use drugs in Castries and Vieux Fort. That data was used for the discussion on vulnerabilities to health issues and impediments to health care.  With the exception of the relocation of Turning Point to the MHMC and the COVID-19 pandemic (with the commissioning of the Owen King EU Hospital) nothing of substance has altered in the provision of care for this population and the investigator felt the material remained valid despite the intervening years.

Secondary data sources include information from a 2012 OAS/CICAD School survey (published in 2016) and the OAS/CICAD Prison Survey results published in 2012.

An inception meeting with MOH stakeholders was held at the beginning of the assessment to discuss the objective of the assessment and the limitations based on the lack of ethical reviews and the 30- day time frame allotted. A number of individuals deemed stakeholders but not affected persons were informed of the assessment and queried for any relevant information.

Written questions were submitted to:

1. Director of Turning Point regarding compliance with international standards
2. MOH Central Procurement on diversion of psychoactive pharmaceuticals
3. RSLPF – protocols for addressing illness among individuals held in police custody
4. SLMDA KAB of Turning Point – President Merle Clarke declined to participate due to the lack of ethical review.

Legislation that was reviewed

• CHAPTER 3.02 DRUGS (PREVENTION OF MISUSE) ACT Revised Edition 31 December 2008
• The Saint Lucia Labour Code 2006
• Health Professionals Act 2006
• Health Practitioners (Allied Health Practitioners) Regulations SI 94 2015
• Public Health Act of 1975
• Millennium Heights Medical Complex (MHMC) Act No1 of 2015
• Liquor License Act chapter 13.17 December 2005

The Process

The methodology employed in the preparation of this assessment was a combination of an exhaustive desk review of literature augmented by a virtual participatory consultative process, managed by the Director of Turning Point. Participants were drawn from Ministry of Health, the members of the Drug Information Network (DIN) of the Substance Abuse Advisory Council Secretariat (SAACS), and the investigator.

The first session informing the assessment strategy was held on 4 November 2020 in which members of staff from Turning Point, the Corporate Planning Unit, and the Substance Abuse Advisory Council Secretariat were present.  These organizations were given the opportunity to input into the implementation plan and at the conclusion provided a consensus on the priority issues that would be addressed by this exercise.

Apart from this inception meeting, written questions were submitted to representatives of a range of organizations – both Governmental and civil society- to obtain current information to augment the desk review.

Country profile

Saint Lucia is an independent country located in the Eastern Caribbean. It became independent from Britain in 1979.  It is the most populated and developed of the independent countries of the Windward or Leeward Islands and is a member and the headquarters of the Organisation of Eastern Caribbean States (OECS).

The population of Saint Lucia was estimated to be 182,000 in 2019. Due to COVID-19 the 2020 Census was postponed. The country is a mountainous volcanic island, has a land mass of 619 square kilometres and has a rain forest in the mountainous interior.

The official language spoken is English; however, Kweyol (Creole) is the cradle language of the countryside and a large majority of the francophone indigenous population. Christianity is the predominant religion of Saint Lucia with 92% of the population belonging to the Roman Catholic Church in 1960. By 2011 this has dropped to less than 60% due to the recent emergence of other Christian denominations. Many of these churches eschew alcohol and drugs. Their members account for the 40% of Saint Lucia who do not drink or use drugs.

Saint Lucia has a parliamentary system of representative governance. The Governor General- the representative of the Queen of England- is the Head of State. Political power rests with the Prime Minister and the Cabinet of Ministers.  There is universal primary education.

There is an extensive system of primary health care facilities[3] throughout Saint Lucia that are staffed by dedicated and competent “community nurses”. Excellent free pre-natal care has kept maternal and infant mortality low and despite the poverty, an increasing life expectancy among the population. With the advent of prevention interventions designed to control the transmission of HIV, the rise in sexual and reproductive health information and interventions[4] and the availability of condoms have resulted in falling fertility rate. Saint Lucia is below population replenishment rate.

The 2020 Human Development indicators rank Saint Lucia as a high human development country, with a ranking of 89 out of 189 countries. Life expectancy (SDG3) at birth is 76.1 years and expected years of schooling almost 14 years (SDG4.3) with a mean of 8.5 years (SDG4.6). Gross national income (GNI) per capita (PPP $) $11,528 (SDG 8.5).

Governmental Structure for Drug Control

The Substance Abuse Advisory Council Secretariat (SAACS) is the Governmental department charged, “to foster a drug free Saint Lucia”. The legislation outlines membership in the Substance Abuse Advisory Council. Membership is drawn solely from Government and does not include representation from civil society.

The objective of the SAACS is to develop, monitor and coordinate an effective and supportive campaign against the Supply and Demand for illicit drugs and the reduction of the abuse of licit substances. SAACS states that there is need for a balanced and coordinated approach, though the SAACS has little control over supply control operations that are the exclusive purview of the Royal Saint Lucia Police Force. Saint Lucia’s Drugs (Prevention of Misuse) Act[5], makes no mention of treatment, education, after care and social reintegration, as an alternative to imprisonment.

Existing treatment services

The Millennium Heights Medical Complex (MHMC) Act No1 of 2015 Section 37 2(m) recognises the need for treatment services to be established at the MHMC, formalising the relocation of Turning Point Drug & Rehabilitation Centre.

Turning Point Drug & Alcohol Rehabilitation Centre moved from its location of 25 years at La Toc, Castries to a new facility within what is now called the Millennium Heights Medical Complex (MHMC). The MHMC also houses the National Mental Wellness Centre and the Owen King EU Hospital.

Turning Point Rehabilitation Centre, an eighteen-bed residential treatment facility is the only drug treatment centre in Saint Lucia and serves both a local and regional population. Turning Point offers a comprehensive program that is designed to help clients to recover from drug dependence or addiction, and return to productive living. Services include Diagnosis & evaluation, medically supervised detoxification, addiction & drug education, psycho-social assessment and treatment planning, individual therapy, group and family therapy, life skills training, relapse prevention management, the 12 step spiritual program, good nutrition and general nursing care, after-care and follow up counselling.

The Centres view of drug treatment is that of the medical, bio-psychosocial model. Therapies are brief, utilising the solution-focused and cognitive-behavioural approaches and are offered with the option of a six (6) week residential stay or as an out-patient.

Over the past seven years (2013-2019), annual admission rates range from 54-86. In 2020 (January to September), the facility recorded 23 admissions, less than a half of previous annual rates.

The staff was asked to gauge residents’ perception of their satisfaction with the care received based on commonly voiced complaints. A query of the Turning Point staff, by the Director, on behalf of the investigator produced this list of the most commonly heard complaints from clients at Turning Point:

• the programme is too rigid. Feels like prison
• lack of resources to facilitate fulfilling and entertaining activities
• there is too much idle time (boredom) especially on weekends
• the programme is too repetitious
• the limited contact with family during treatment
• the lack of technology to facilitate contact with family
• dissatisfaction with the quality and variety of meals available

Legislative Review

Review relevant legislation and policies related to the management of persons with Substance Use Issues and the treatment of the disease and provide recommendations for changes to legislations and policies, as necessary.

Saint Lucia has no legislation, no regulations or standards that address the management or treatment of persons with substance use issue or the operation of a private drug treatment programme. There are no specific national standards for set out to guide the provision of care or the operation of drug treatment centres.

A person, not subject to immigration restrictions could house people in a residence and provide “drug treatment” without any oversight authorised any legislation or instrument published in the Saint Lucia Gazette

The DRUGS (PREVENTION OF MISUSE) ACT Revised Edition 2008 makes no mention of drug treatment or the institution of Turning Point. The law is primarily regulatory in nature and sets out criminal justice penalties for breeches.

Saint Lucia’s National Drug Plan

The draft of Saint Lucia’s National Drug Plan moves away from an abstinent based, “just say no” foundation and adopts a more accessible public health, harm reduction approach to the drug use. The new plan seeks to increase utilization of drugs service by improving the quality of treatment and rehabilitation, and adding community based and aftercare recovery programmes, for individuals with substance use issues.

The Plan calls for the creation of a steering committee to oversee the implementation of the Drug Policy and support the work of the National Drug Observatory.

It would be better to review the membership and terms of reference of the Substance Abuse Advisory Council in the Drugs Act and work towards getting that institution functioning and have it carry out the role envisaged in the steering committee. The Act should be amended to include representatives of civil society on the Council.

The Saint Lucia Labour Code 2006

The labour code makes no mention of drug treatment except in section 56 prohibits and makes an offense that the “remuneration other than wages may NOT be in the form of intoxicating liquor, tobacco, cigarettes, noxious drug or substance, or weapons and on summary conviction libel to a fine not exceeding ten thousand dollars.

Health Professionals Act 2006

Health Professionals Act 2006, safeguards public health by ensuring that allied health professionals are properly credentialed and experienced. These allied medical practitioners include dental hygienists, occupational therapists, herbalists, emergency medical dispatchers, massage therapists and opticians. There is a reference to psychologist and social worker but no mention of drugs counselor or related practitioners.

Health Practitioners (Allied Health Practitioners) Regulations

This makes no mention of drugs or drug treatment but does regulate the qualifications of individuals calling themselves Psychotherapist, Psychologist or Social Worker all positions that would find roles in drug treatment. Registered practitioners are required to sign a code of ethics document.

Millennium Heights Medical Complex Act (2015) (MHMC)

The only legislative mention of Turning Point Drug & Alcohol Rehabilitation Centre is in the MHMC and then only that it is under the authority of the Board of Directors of the MHMC and subject to the same general set of quality standards that apply to all institutions on the Complex.

Liquor License Act chapter 13.17 December 2005

Section 65 outlines the procedure to be taken if an individual becomes “drunken, or quarrelsome, or a disorderly person” in an establishment: all necessary force not extending to a blow or wound or grievous or dangerous harm. So, you could grab and drag a drunk out of the bar but not beat or stab them whilst doing it. The ultimate penalty for multiple non-compliance, is arrest and fine of $50 XCD.

Saint Lucia has introduced an amendment to the Public Health (Smoking Control) Act, 2019; and the Public Health (Smoking Control) Regulations, 2020  designed to control tobacco smoking and reduce the harmful exposure of smoking in public places and work places.

Cannabis Legalization

The Saint Lucia Cannabis Commission was established by the Government of Saint Lucia in 2019 to review and make recommendations on the laws and regulations as it relates to cannabis. The mandate of the Commission was to explore changes to the Drugs (Prevention of Misuse) Act to create a regulated environment that minimizes harms and maximizes benefits.

A press release dated 20 November 2020, outlined the progress for implementing a regulated regime for cannabis in Saint Lucia in early 2021. The Cannabis Movement of Saint Lucia has advocated for the inclusion of cannabis in the tobacco control regulations to regulate all public smoking in one piece of legislation.

The legalization of Cannabis in Saint Lucia will require adjustments to the drugs education programme, moving away from framing cannabis as a dangerous drug to that of a beneficial medicine that should be treated with respect.

Results and discussion

COVID-19 and its impact on the economy of Saint Lucia

The COVID-19 pandemic has precipitated steep recessions in many countries. The baseline forecast envisions a 5.2% contraction in global GDP in 2020, the deepest global recession in eight decades, despite unprecedented policy support[6]. By comparison, the Caribbean Development Bank (CDB) estimates that due to its heavy reliance on tourism, the GDP of Saint Lucia will contract by 19% in 2020[7].

The informal sector comprises an estimated one-third of the GDP and about 40% of total employment in Saint Lucia. Individuals whose livelihoods rely on informal sector participation are experiencing a greater negative humanitarian and economic impact than Government or financial services workers. Tourism accounts for another one third of the GDP. The greatly reduced numbers of overnight visitors and the complete cessation of cruise ship stops have resulted in massive unemployment, further compounding the crisis.

With a rise in unemployment and a steep decline in “bounce and draw” as day work is referred to, per capita incomes have been reduced.

Risk factors contributing to drug use vulnerability in Saint Lucia.

Poverty

Saint Lucia has high levels of poverty – 25.1% in 1995 growing to 28.8% in 2005/06 with over 50% of the poor under the age of 20 years. The incidence of poverty among men is slightly higher than among women, 29% and 25% respectively. With employment peaking in 2019, the effects of poverty were somewhat alleviated.  Thirty-nine per cent of the population who were identified as being poor were in the age group 0 – 14 years. Households with single parents were more likely to be at risk of being poor. The cycle of poverty had a correlating effect on this vulnerable populations ability to access employment.

Geographical location

Saint Lucia is on an active drug trafficking route between the cocaine producers in South America and the European consumer market. Cocaine arrives in Saint Lucia through various commercial routes, is transferred to yachts and fishing pirogues for transit to Martinique. The yacht traffic has halted because of the pandemic but pirogues still transit the channel under the guise of fishing. Isolated sea coasts, weak law enforcement and border controls, and corruption, all contribute to Saint Lucia’s success as a transhipment point for cocaine.

It is reported that payment’ to locals to facilitate the transfer of cocaine with the payment for the transit of cocaine is done in cocaine. This payment with product is the reason uncut cocaine is plentiful and inexpensive in Saint Lucia.

The state of health care in Saint Lucia

Health Care in Saint Lucia has been in flux. Discussions of universal health care have been ongoing since 1997, with finance models being the primary hurdle to implementation.

The initial cases of COVID-19 forced the Government of St Lucia (GOSL) to commission the Owen King EU Hospital as the national general hospital in a record time of one week.  Victoria Hospital was converted to a specialized respiratory hospital for COVID-19 patients. The GoSL also converted 3 primary care health centres to special respiratory testing centres spread throughout the island to serve as primary centres for identifying new COVID-19 cases.

Prior to COVID-19 there was a well-structured clinic system where patients could present on a 1^st come 1^st serve basis. This was disrupted during the initial lock downs but is finding a “new normal” with appointments rather than presenting unannounced.

Changes in the employment profile

While tourism did create new employment opportunities and foreign exchange earnings, two effects were evident: the uneven distribution of new jobs and the contraction of the “cash” circulating in the local economy.

The current situation is grim: high unemployment rates[8] among young males resulted in large blocks of idle young men with a limited skill set to provide for their daily upkeep.  Compounding the employment challenges is the high percentage of cannabis use among this population.

Unsupervised children

Female heads of households who joined the migration and found employment soon realized that they would need to leave their children unsupervised either at home or on the school grounds while they worked.

As some of these young men aged up, they moved from their mother’s house and found their way into the poorer communities that usually lie adjacent to more upscale communities seeking opportunities to generate some income.  These internal migrants congregated in these “ghettos”, resulting in high concentrations of unemployment and poverty, poor housing options and a feeling of dislocation brought on by a separation from the extended family and support systems of the “village”. When asked about why young men congregate together in these areas one key informant said “Once you’re “strapped” you will find a clan – more food and more ‘firepower’”.

Who are the drug using populations?

The profile of people who use drugs is the profile of the people of Saint Lucia. Substance use knows no class, race, or ethnicity. Seeking an altered state of consciousness is a part of the human experience, both with substances or without.

Many have been conditioned for instant gratification, and consider it simpler to have a drink, to take a pill, to have a smoke with the illusion of all existing problems fading away quickly if only temporarily.

For some the occasional use of substances is enough, an end of the day cocktail to de-stress from the day, with maybe a Friday night alcohol binge. Alcohol disinhibition is sought, allowing the alcohol to bring out the real inner person.

Occasional cannabis users have a similar profile to the occasional alcohol user. They smoke on occasion, maybe on the weekend. Others will smoke each evening after work but don’t go to work stoned and confines day smoking as a weekend lime. The cannabis binger suffers less physical repercussions from the weekend of immoderate cannabis use than the alcohol user.

Some of those occasional cannabis users may indulge further by mixing some crack into their cannabis, referred to as a black joint. A fifth of those interviewed in a 2007 behavioural and sero-prevalence study of people who smoke crack reported their first crack was a black joint, provided by a friend, sometimes not even knowing it was crack but thinking this is really good weed.

In Saint Lucia a small minority of cannabis users smoke crack but a majority of crack smokers prefer mixing their crack with cannabis. Crack is used by some as a method for obtaining sex with or without consent.

Piping is considered hard core and the preferred method of use for a subsection of people who smoke crack cocaine.  In Saint Lucia many of the homeless people who pipe crack cocaine are known to the psychiatric hospital.

The homeless population of Castries is largely made up of people who smoke crack or drink alcohol excessively and have co-occurring psychiatric issues. Possible interventions for this population range from prescribing prescription medications, teaching moderation management and educating on the value of switching to lesser harmful substances.

Women

Cocaine is often used to get sex, men enticing women, men enticing men, women enticing women. Sex and drugs are intertwined. Before COVID-19 it was well known that many tourists would buy cocaine for their pleasure and the pleasure of a locally acquired partner. The tourist dynamic for alcohol is similar but more public. Some women will go to clubs hoping to find a sugar daddy often consuming as much alcohol as will be bought for her.

There are women, who make it their job to hang around tourists’ areas, on the beach or in the evenings for alcohol, drugs, money or sex opportunities. Random scans of internet hook up sites, and cannabis information chats reveal that tourists are still engaged in drug seeking behaviours despite COVID-19 protocols prohibiting the mixing of tourists and residents.

Women in Saint Lucia are less likely to access and utilize drug and alcohol treatment than men, as is apparent by the ratio of men to women attending treatment services at Turning Point.

Women in Saint Lucia who smoke crack cocaine or use alcohol to excess face multiple barriers to accessing services, these include:

• stigma, both in society in general and from community and hospital health workers;
• gender-based violence and negative repercussions from a partner or spouse
• no services that address the interaction between drug use and experiences of violence; harassment from law enforcement,
• lack of services focused on the specific needs of women,
  • sexual and reproductive health services
  • childcare.

The mixing of men and women in treatment is not conducive to the well-being of the women. Women in Saint Lucia bear a high burden of previous abuse, sexual, physical, and/or verbal. Substance use is often a form of self-medication for unresolved trauma, post-traumatic stress disorder. Women in small communities like Saint Lucia often find themselves in treatment with men that they have had previous relationships with. Often this is counterproductive in their recovery path. From the table 1. below we see that Turning Point is consistently underutilized by women. We ?posit if a specialized service for women, run by women would have a greater service utilization.

 

Table 1: Turning Point Admissions by Gender 2013 – 2019
Year	Total	Male	Re-admit		Female	Re-admit
2019	54	42	8	78%	12	5	22%
2018	64	52	16	81%	12	4	19%
2017	59	47	5	80%	12	3	20%
2016	59	54	5	92%	5	0	8%
2015	86	77	1	90%	9	1	10%
2014	62	50	8	81%	12	2	19%
2013	60	49	10	82%	11	4	18%

Gay men and Chemsex

Chemsex is formally defined by two features, using geo-enabled apps like Grindr or Adam for Adam used by gay men to acquire a sex partner and the concurrent use of certain synthetic psychoactive substances to facilitate and heighten sexual enjoyment. Despite an active presence on these ‘hook up’ sites by Saint Lucian men, there have been little indication of this happening in Saint Lucia.

These ‘sex hook up’ sites were very busy prior to the pandemic with a regular mix of overnight tourist, cruise ship passengers/crews and airline crews. Drug use initiation is often by exposure opportunities. Prevention messaging should be devised to educating our men on the risks associated with concurrent sex and drug use.

Alcohol and LBGT people

Alcohol use is very high in a segment of the community of lesbian, bisexual, gay men and transgender individuals. The disinhibition of alcohol is the lubricant for sex in a homophobic hetero-normative society.

Licit/illicit substances used in Saint Lucia

The following are the common drugs (legal and illegal) used in Saint Lucia:

1. • alcohol
   • cannabis
   • tobacco
   • cocaine (smokable and powder)
   • caffeine (of primary concern when mixed with alcohol)
   • controlled pharmaceuticals
   • inhalants

Hashish is found in some local drug markets that have connections to the drug trade with Martinique. Hash from North Africa transits Paris and is available in Martinique. Hash is used to barter for herbal cannabis or cocaine arriving from Saint Lucia.

Diversion of pharmaceuticals

In an exchange of emails querying diversion of opioid pharmaceuticals with the Chief Pharmacist, she stated that she believed there were diversion of pharmaceuticals by way of individuals forging prescriptions to obtain these substances. It is unclear if these substances are being used for pain relief or “recreational”, though no one with an issue with pharmaceuticals has presented for treatment at Turning Point.

Routes of administration of the drugs being used

Crack cocaine and cannabis are administered through inhalation. Cannabis is wrapped in paper, set a light, and inhaled. Cannabis may also be smoked from a regular pipe or variations of a water piper.  Crack may be mixed with cannabis in the same cigarette or smoked in a small pipe. Alcohol is taken orally and is widely available in individual portions or shots. There is no injecting drug use that has ever been encountered by law enforcement or treatment services.

Drug Use Prevalence in 25-64 years age population by Drug

Cannabis Use and Cocaine Use

1. • cannabis, 40%
   • crack cocaine 3%

The illicit drug markets in Saint Lucia

Locally grown cannabis is available throughout the island and obtaining it is easy and inexpensive. Anyone who wishes to use cannabis would have no issue obtaining it.

Imported cannabis is also available but distribution is more limited and prices higher. Higher THC cannabis, such as creepy, hydro, are also available, creepy being imported and hydro either imported or locally cultivated.

Crack cocaine is also available throughout the island. Based on interviews conducted in a cannabis vendors survey, it is estimated that 5% of cannabis sellers also sell crack cocaine.   Powder cocaine is not as widely available but can be found in proximity to tourist locations. With COVID-19 and the lack of tourists there are indications that powder cocaine may be slipping into the local market – it being the only market available besides Martinique.

There are no illicit or diverted opioids, no synthetic stimulants or new psychoactive substances (NPS) in the drug markets of Saint Lucia that we have detected. This statement is supported by two indicators:

1. None of these substances have been interdicted by our authorities, either at sea or on land.
2. No one has presented in the health system with symptoms indicating opioid withdrawals, nor has Turning Point seen anyone presenting with an opioid dependency in their intake.

The procurement officer at the MoH stated that there was no evidence or indication of diversion of prescription drugs. She also stated that naloxone is available but used by physicians to revive a patient after surgery.

Methadone was recently added to the essential medicines list.  The formulary is revised every 2 years by the OECS/PPS Technical Advisory Committee. The reasons for including Methadone on the formulary are:

• Potent analgesic and provided another option for treating chronic pain
• Short onset of action
• Long duration of effect
• Could be used for patients who may not be able to tolerate morphine

We were told by Central Procurement that even though it’s been approved, it has not been imported.

Determining the level of demand for drug treatment services

Determining treatment needs in real numbers was an interesting exercise to undertake. To attain a reasonable estimate, we made the assumption that not everyone who uses drugs or alcohol require drug treatment. Some people use drugs socially and never have an issue or disruption in their life. Others who have co-occurring psychiatric issues maybe better managed by a psychiatrist with prescribed psychotropic medications. When we consider people who may require drug or alcohol treatment, those who are most dysfunctional come to mind.  Population wide “dysfunctionality” due to substance use was estimated using data collected in the OAS/CICAD secondary school data.

Students were asked to indicate, using a 5- point Likert scale, to rate the degree of disruption substance use caused them from “never” to “almost always”.

The percentage of persons answering “almost always” for each of the indicators was from .1% to 2.3%.

The indicators used in this survey were:

• Getting a low grade on an important test/ exam or school project
• Getting into some kind of trouble with the police
• Getting into any angry argument or fight
• Memory loss
• Problems with your family/relatives/ households
• Having someone take sexual advantage of you.
• Taking sexual advantage of someone.
• Trying without success to stop drinking alcohol or taking illicit drugs
• Self-harm (such as self-cutting, burning, hitting, etc.)
• Seriously thinking about committing suicide

Alcohol

Alcohol is the most used substance under review.  As noted, 70% of males and 45% of females drink alcohol. From that same 2012 Step study, almost half the men (49.5%) and a fifth of females (19.5%) engaged in heavy episodic drinking, defined as 5 or more drinks for men or 4 or more drinks for a female on any day in the past 30 days.

Cannabis

Though illegal, cannabis use is pervasive throughout Saint Lucia. Cannabis is used by a significant number of people in Saint Lucia, across all social strata, from the boys on the block, the labourer, to offices and executive suites. Cannabis use in private is tolerated with law enforcement focused on public use, targeting the most visible user, the boys on the block.

Cannabis use, while widespread, is highly stigmatized and as mentioned above, its possession criminalized. Drug law enforcement targets public use, which is the predominant method of consumption of street engaged young men or as they are often referred to “boys of the block”.  This contact with the criminal justice system, initially for cannabis contributes to the relentless slide into criminality for males due to their mere association with cannabis.

Penalties for students who are caught with cannabis at school or in uniform have been known to be stringent. Cannabis use is usually dealt with by suspension, or even expulsion if over the age of 16 years. When Turning Point was at its former location in La Toc, it is not uncommon to see a young male in school uniform waiting for the bus outside Turning Point, where they had been placed by their family because of their cannabis use. Repeat offenders, especially those who used cannabis in public spaces were remanded to the Boys Training Centre for “care and protection”.

A CICAD funded school survey on drug and alcohol use conducted by the Government of Saint Lucia reported that 43.4% of the males in the 17 – 20 year old cohort[9] reported a life time use of Cannabis, with 31% males reporting use in the past year and 19.8% in the past month. These figures reflect males who were currently enrolled in a formal educational programme. It is important to place these figures in context of the survey which was conducted in the secondary schools and the A level college. Out of school youth and older males were not included in the sample frame. The author postulates that the prevalence of cannabis use for unemployed young men will be higher, if merely for the lack of an alternative activity.

The dynamics of how cannabis contributes to the growth of young male urban migrants is complex. We postulate that social stigma surrounding cannabis use, perpetrated by a drug prevention programme that has demonized cannabis use far in excess to any attributable physical harms associated with its use.  When this stigma is applied at home it becomes a major motivator for young men to leave the security of their family home and take refuge in “cannabis friendly” ghetto communities with other young men who smoke cannabis.

Findings in a recent prison study conducted in Saint Lucia in 2012 revealed that the lifetime prevalence of marijuana use by first time offenders (remand or convicted) was 76.5%[10].  For the recidivists (remand or convicted), the lifetime prevalence of marijuana use was 85.7%[11]. Additional to any physical harms or benefits that may or may not be attributable to cannabis use, just the mere act of using in an environment of strict cannabis law enforcement contributes to the growth of a pool of young men whose exposure to criminality was public use of cannabis.

An examination of the profile of the participants of this prison study is interesting in that it reflects the population that is representational of this underclass of marginalized, undereducated young men. Of the prisoners surveyed 65.7% fall in the age group 16 – 35 years, 31% never completed primary school and an additional 44% never completed secondary school and over 60% had a history of cannabis use.

Slightly less visible though as geographically dispersed across Saint Lucia is the growing of cannabis. An additional indicator of this pool of idle cannabis using young men with agricultural skills is the proliferation of small scale decentralised cannabis production in the same mysterious mountains and isolated valleys used by the brigands of the past. The cannabis growers’ model is independent small subsistent farmers, using their gardens to replace income lost due to the contraction of banana cultivation. Findings from a survey of cannabis markets in the north supported the diversity of cannabis cultivation with many identifiably different strains and types of cannabis for sale in a relatively small geographical area.

With the acceptance and legalisation of medical cannabis in other countries, notably the USA, Canada and Jamaica, more people in Saint Lucia are expressing an interest in medical cannabis. The Cabinet of Ministers is moving forward to create a framework for religious, medical, industrial and personal use, creating a regulated cannabis market in Saint Lucia.

Treatment issues related to cannabis use

The issue of treatment needs of people who use cannabis is controversial with new peer reviewed data being published regularly. There is evidence that some individuals have issues with cannabis and its use that may require interventions by professionals. Cannabis, especially with a high THC content that is out of balance with the CBD and other cannabinoids may trigger negative reactions in people with pre-existing, possibly undiagnosed psychiatric issues.

The discovery of the human endocannabinoid system and how receptors’ uptake of cannabinoids found in cannabis are therapeutic is changing the way cannabis use is viewed. Since 1998 US Scientists have researched people who use medical cannabis, providing cohorts of individuals to study. These individuals are no longer a hidden population of criminals but they are patients under the care of a physician. Important findings are being published in peer reviewed scientific journals citing an ever- increasing amount of positive data on important therapeutic qualities of cannabis.

Daily crack smokers

The most visible population of crack cocaine users are the homeless population of the urban centre of Castries, Vieux Fort and Soufriere. Many of these people are known to the Wellness Centre and have psychiatric co-morbidities. Managing these people in a quarantine environment would be challenging.

Occasional crack smokers

There are a number of people who smoke crack occasionally. This is a very hidden population given the stigma associated with being identified as a crack smoker. The crack is usually mixed with cannabis and smoked in a joint or spliff further concealing it. Some of these occasional crack smokers will become regular users and possibly impoverished from financing their consumption.

Powder cocaine

Saint Lucia is a transit country. The cocaine here is a product of that trade, it is very pure and much less expensive when compared to the destination countries. Local traffickers are paid in cocaine for moving product and eager to convert it to cash, selling it cheap.

Inhalants

Inhalant use regularly shows up on the secondary school surveys. First use is averaged at age 11 years, 21% declaring life time use, 11% used in the past year and 6.8% used in the last month. There was also a high awareness among those surveyed as to the danger of inhalants with 40% stating they felt even occasional use was dangerous while 60% agreed that regular use was not good.

Harm reduction / Treatment issues

In terms of residential treatment needs, persons who are alcohol dependent require medically supervised detoxification. They have the highest need for inpatient care and need to be recognised as such. People who smoke crack cocaine do not have the same medical issues associated with cessation of use as with people dependent on alcohol.

One issue to raise with people who are trying to stop smoking cocaine is the risk of substituting alcohol for cocaine. The disinhibiting effects of alcohol may lead to the smoking of crack cocaine leading to the production of cocaethylene in the liver, a substance that has been associated with negative cardiovascular outcomes.

The community of people who use drugs, peer workers and front- line arm reduction providers have long recognised the moderating effect of cannabis on crack use. The evidence that supports this community belief is being studied and published, but has gained little attention from the authorities or the treatment industry.

In the Caribbean where cannabis smoking was common and where there was always an aversion to injection and needles, smoking crack cocaine became the preferred method of use. This is attributable to unsophisticated smokers seeing smokable cocaine as similar to smoking cannabis. “Smoke is smoke” as people would say.

It has been suggested that smoke-able cocaine users engage in high levels of transactional sex to fund their drug use. Some smoke-able cocaine users will smoke for multiple days (bingeing) and become drug-obsessed. The obsession is so all-consuming that food, money, sleep, are eclipsed and sex work without condom use and for minimal amounts of money, usually enough for the next “rock”, is used to fund the continued use.

Police Custody and medical emergencies

When one is in police custody, they enjoy certain rights which the police are under an obligation to recognize and provide. Standard operating procedures are maintained when addressing the needs of prisoners at all stations. These procedures are in the form of memorandum rather than “protocols” but do lay out the procedure if an inmate falls sick in the custody of the police. If that is the case they are taken to the nearest medical facility for treatment.

When one is taken into custody, questions on the person’s health, diet etc. are asked. Therefore, if one is on medication, the medication is obtained and placed amongst the person’s belongings. The custodian then ensures that the medication is taken as directed by the doctor.

The increase in imprisonment rates since the 1980s and the importation of the US war on drugs, has left Caribbean prisons with severe overcrowding problems.[12] As a result, Caribbean prisons are filled beyond capacity, and has one of the highest rates of imprisonment in the world.

Tobacco

Tobacco places a person at risk for health consequences such as cancer and lung damage. In addition to smoking, emerging evidence suggests that vaping certain products causes damage to lung cells and inflammation to lung tissue. This reduces the ability of the lungs to respond to infection. Because COVID-19 attacks the lungs, smoking and vaping may pose serious risks to those who contract COVID-19.

Tobacco is the only legal product that is guaranteed to harm and eventually kill 100% of its consumers. The recommendations of this assessment support the introduction of tobacco cessation programmes at the community level. It is recommended that a harm reduction philosophy be adopted in addressing the needs of people who may be dealing with issues far more problematic than immediate tobacco use. The use of comfort substances in the proximity of a low threshold quarantine centres should not be prohibited. Spaces should be designated for smoking as to not affect other residents.

The amendment of the Public Health Act in 2019 addressed some of the key public health issues that were not an issue in 1975 when the Act was originally passed. [13]The revised Public Health Act (2019) addresses smoking of tobacco products in public spaces, one area not addressed in 1975. The Act prohibits public smoking. Tobacco smoking may only occur in designated spaces.

Tobacco Harm Reduction Messaging

It is the mixing of tobacco with cannabis that increases the early onset of COPD[14].  In a 2012 Step report by the Ministry of Health, it was found that approximately 21% of males age 25-64 years used tobacco but did not smoke commercially manufactured cigarettes. Within that 20% must be a number of cannabis smokers who are accustomed to mixing cigarette or black tobacco with their cannabis.

Tobacco harm reduction supports people in reducing tobacco harm by using safer nicotine products (SNP) including vaping devices (e-cigarettes), heated tobacco products (HTP), and pasteurised oral snus, improving health and reducing deaths by enabling people to use nicotine without the smoke that causes disease.

Access and utilisation of health care services by people who use drugs

Current data on impediments and barriers to access and utilisation of health care services was unobtainable due to the lack of ethical review. In its stead, data collected in 2007 on access and utilisation of health care services is cited below. This data was obtained from a behavioural and sero-prevalence study conducted in the city of Castries by Dr Marcus Day and his team from the Caribbean Drug and Alcohol Research Institute.

At that time 206 persons deemed homeless, and having substance use issues were recruited in Castries for an HIV/Crack use study.  A structured instrument composed of 211 questions was administered. The interviews were anonymous and confidential.  The questionnaire was 70% quantitative and 30% qualitative questions. To be eligible to participate, participants had to be at least 18 years of age; be homeless and to have used crack cocaine in the past year.

Modified targeted sampling, which involved recruiting participants from geographical areas previously identified by the researcher and known to be frequented by the targeted population, was utilised for recruitment in this study. The data cited here was previously unanalysed and unpublished.

Participant’s Profile

77% reported crack use and 72% cannabis use in the past month. Approximately the same percentage smoked tobacco products (77%) and 74% drank alcohol.

52% reported using the emergency services at Victoria Hospital, 40% the local health centre and 12% a private physician. It will be interesting to see if this pattern has changed with the opening of the Owen King EU Hospital located outside of the city of Castries and the impending refurbishment of the Castries health Centre.

The majority of the respondents (81%) agreeing that there were not enough services for drug users and 49% stated that the services on offer were meeting their health care needs.

Table 2 outlines the barriers to health care taken from two surveys conducted in Castries. The respondents were asked their opinions about health care. This was measured by 19 indicators. When asked if the community health care workers were meeting their needs, 51% replied yes, and this is up from 40% in 2002.

Table 2: Drug Use Prevalence in School Population

The percentage of the Saint Lucian school population age 13-17 years and their consumption licit /illicit substances:

Drug	Time Period	Prevalence %	Time Period	Prevalence %
Alcohol	Last month	63.80	Lifetime	77.30
Cannabis	Last month	15.90	Lifetime	25.50
Tobacco	Last month	5.80	Lifetime	11.30
Cocaine	Last month	0.80	Lifetime	1.50
Inhalants	Last month	5.70	Lifetime	9.70

In spite of the mixed reviews for health care services, approximately 50% of responders stated that they were not reluctant to use the health services.  Of the individuals who said they were reluctant, most felt stigmatised, not by the medical staff, but by the non-medical staff such as receptionists as well as by other patients. Over half of responders thought drug users were not understood. A similar proportion of responders, 61.5%, in Saint Lucia, felt that medical staff did not have enough knowledge about drugs or drug users’ issues to be effective.

When asked if they thought more peer worker programs and outreach services would improve their conditions, 85% of the sample answered affirmatively.  People were also asked if they would like a specialised service that was designed to undertake health assessments of drug users. Again, the overwhelming majority, 94% (up from 84% in 2002) replied positively, with 88% in 2007, stating that a specialised service would reduce the feelings of prejudice and discrimination that they felt when using mainstream services. This was up from 73% in 2002.

A further set of reactionary questions were asked about the issues that should be considered in establishing a specialised health care service for drug users. The choices given were: Confidentiality, Friendly Staff, Shower Facilities, Free Meals, Counselling Services and Job Placement.

Approximately 38% of the respondents in Saint Lucia chose “job placement” as their first option with a specialised health care service, with 29% selecting “counselling” as their second option.

Findings: Gaps and challenges in research, advocacy and skills

Gaps in Research:

There is insufficient information available on

1. the impact of the COVID-19 pandemic on the social determinants of health of people who use drugs in Saint Lucia.

2. the impact of the COVID-19 pandemic on drug use and demand for drug treatment services at Turning Point

3. the need for community- based services for people who use drugs and people who use alcohol

4. changes in drug use patterns and risk practices caused by immigration, mobile populations

5. the collection, dissemination and use of standardised drug and alcohol data collection and reporting instruments in use throughout the health system.

6. barriers to access and utilisation of health care services for people who use drugs

• on the effects of drug criminalisation laws on health care access
• the impact of compliance to human rights norms on health care access

7. causes of death from COVID-19 with overlap with drug or alcohol use and pre-existing conditions

8. no data from prisons on COVID-19 and its impact on incarcerated people who have NCDs and other pre-existing conditions including nutritional support.

9. no data on follow up of inmates’ releases and the continuation of their health services after release.

10. the impact of COVID-19 on current and former tuberculosis (TB) patients

Gaps in Research Skills

1. Utilising methods of self-evaluation to continually monitor and evaluate services provided by Turning Point
2. applying methodologies that have proven effective in sampling other small populations such as Respondent Driven Sampling

Gaps about Advocacy:

There is a lack advocacy:

1. on opening the wider debate of social inequality and poverty, and harm reduction
   • for greater coordination between social services, health, justice, education in addressing the issues of people who use drugs
   • for the inclusion of a harm reduction philosophy in non-drug specific social services such as but not limited to housing service, poverty reduction, employment programme, social nets
2. for political support and ownership of harm reduction as a mainstream intervention
3. for evidence- based policy and programme formation that includes the greater involvement of affected populations and service providers into developing research that yields practical applications
4. for increased resources in the region for advocacy, prevention, treatment and care for people who use drugs to ensure service sustainability
5. for the inclusion of harm reduction strategies in public health policies with accompanying budgetary allocations
6. for the reduction in stigma and discrimination of people who use drugs
7. for the greater involvement of people who use drugs in all aspects of this work
8. for the application of human rights standard to people who use drugs
9. for all services to meet agreed international human rights standards

• for the equivalency of and availability of services in prison with the community

Gaps in Intervention:

There is a lack of:

1. a harm reduction application in social programming, poverty reduction and other social services or health services
2. alternative low threshold harm reduction models of drug treatment
3. access for people who use drugs to hepatitis prevention, vaccines, treatment and care
4. availability of diversified drug treatment services, such as treatment opportunities tailored to individual needs, government finances for non-governmental sector services for harm reduction and street based programmes
5. training for health care teams in practical applications of harm reduction
6. prompt consideration of research findings and investigations into response interventions
7. programming based on best practices informed by peer review science

8. access and utilisation of treatment and care for people who use drugs due to criminalisation and stigmatisation
9. meaningful participation of people who use drugs in the design and / or implementation of interventions

Challenges:

Challenges in Research:

1. To systematically and consistently produce strategic information that is accessible and retrievable for analysis. The ability to track the impact of harm reduction interventions, allowing for comparisons of trends, documenting harm reduction interventions that target people who use drugs and the impact of such interventions on disease burden.
2. To identify and describe macro and mid-level social and economic changes that create, sustain or reduce high-risk patterns of behaviours that contribute to COVID-19 and other infection transmission and, most importantly, to determine how to effectively intervene to reduce transmission risk.
3. To expand and establish collaborations among teams from the different ministries and organisations for a more holistic approach.
4. For governmental, academic, non-governmental and community-based organisations to build and use comparative tools for data collection, research design and program evaluation.
5. To conduct further research on people who use drugs and/or alcohol in a manner that interrogates their vulnerabilities, in order to inform evidence- based policies designed to reduce harm.
6. To conduct multi-site research studies to understand factors that influence vulnerabilities of people who use drugs and or alcohol and how they access care, utilising qualitative and quantitative research methods.
7. To expand and support the collaboration between organisations that develop and implement harm reduction programs in the various countries of the region to share knowledge in order to assist other countries in the Caribbean with similar issues.
8. To conduct research on social participation processes as protective factors in the transmission of infections in impoverished communities, for example, how changes in alcohol availability and use during the lock down were related to increased vulnerability to COVID-19.
9. Investigate further inhalant use among young people to inform prevention programmes.
10. To develop studies on how people who used drugs and alcohol access and utilise health care services to provide an evidence base to provide recommendations, make interventions, health and social services personnel more user friendly.
11. To develop a long- term study on the impact of COVID-19 on people who use drugs and alcohol including those who are incarcerated.

Challenges in Intervention:

1. To expand harm reduction ideas and practices in order to broaden its initial focus of HIV to a wider view of preventing COVID-19 and other disease transmission.
2. To include harms and risks associated with drug and alcohol use in integrated harm reduction initiatives.
3. To have scientists, policy makers and donors accept the evidence base for the expansion of harm reduction interventions to people who use drugs who are at risk of COVID-19 or other infectious diseases.
4. To develop and implement interventions that are determined by evidence and research findings rather than political agendas or ideologies.
5. To promote greater cooperation between governmental and non-governmental and community- based organisations to develop measures of harm reduction associated with drug use, both in prisons and other institutions of confinement.
6. To scale up harm reduction services, improve accessibility and utilisation to drug treatment and health care, including diagnosis and treatment of COVID-19 and other infectious and non-communicable diseases.
7. To improve the access of people who use drugs, their partners and children to prevention programs and care of COVID-19 and other infectious diseases.
8. To obtain the social resources needed to assist with reintegration and / or follow up for people who use drugs such as access to housing, employment and nutritional support. This includes inmates recently released from prison and the affected families of people who use drugs.
9. To identify and remove the barriers hindering access to COVID-19 prevention and care for people who use drugs.
10. To expand scope and to improve the capacity and quality, as well as training, of health care teams in strategies of harm reduction.
11. To expand the scope and to improve the capacity and quality, as well as training of persons responsible for designing interventions in methods of rapid assessment and response.
12. To sensitise, and train health providers especially at Turning Point and at primary health care centres to work effectively with people who use drugs from a perspective of harm reduction.
13. To promote the involvement of people who use drugs in the design and implementation of interventions.
14. To establish interventions at the community level.
15. To support activities to detect, diagnose, treat and control prisoner contacts to reduce COVID-19 and TB transmission.
16. To develop information and education activities to avoid discrimination and stigmatisation of prisoners.

Challenges in Advocacy:

1. To advocate for government health and justice services to incorporate a human rights and harm reduction approach into their policies and service delivery.
2. To overcome the misconception that people who use drugs are weak willed.
3. To promote training of health care and social service providers, law enforcement and criminal justice personnel in the responsibilities and commitments imposed by international human rights obligations and harm reduction philosophy.
4. To improve training and staff exchanges in different government sectors responsible for interacting with people who use drugs and in particular on the negative consequences of the criminalisation of the drug users.
5. To promote a debate on supply and demand reduction policies to encourage the formation of policies that support and prioritise a more integrated and coherent approach that supports access and utilisation to health and other drug treatment and social services.
6. To improve consultation with and engagement of civil society when developing harm reduction policies and strategies.
7. To improve consultation with and engagement of affected populations, in this case people who use drugs, when developing infectious and non-communicable disease prevention and harm reduction policies and strategies.
8. To ensure governments consider the negative and often unintended negative consequences of drug legislation and public policy on the public health.
9. To ensure that national policies related to drug supply control and drug demand reduction, as promulgated and promoted by multilateral agencies, are harmonised with national human rights obligations and principles of public health.
10. To ensure that donor funding and national budgets include allocations for harm reduction community advocacy and education.
11. To ensure that people who are incarcerated, as the “wards” of the state, be provided with health care services at the same level as is available in the community.
12. To empower civil society organisations working at the community level to incorporate the perspectives of harm reduction into their interventions.
13. To change the way that the media describes people who use drugs and their social portrayal. Current portrayals are stigmatising especially drug prevention messages that seek to demonise people who use drugs in the name of drug prevention.
14. To advocate for changes in the drug laws that criminalise people who use drugs and creates barriers to their access to health and social services.
15. Sustainable Development Goals (SDG). For people who use drugs to benefit from the SDGs, it will be necessary to apply a harm reduction lens when developing public health strategies. This is necessary for increasing the impact and scope of community-based organisations and governmental and non-governmental organisations that develop infectious disease prevention and outreach programs for people who use drugs.

Conclusion

COVID-19 has forced major changes to the health care system in Saint Lucia, already challenged before the pandemic struck.  The pandemic has exposed the need for health and economic policies designed to protect vulnerable populations, mitigating both the health and economic impact of epidemics like COVID-19. The COVID-19 pandemic has also opened an examination of the delivery and utilisation of health care by all people. The private for fee health service has shown to be wanting when the goal is the protection of the entire nation from an airborne respiratory illness.

The national health and wellbeing require that health care and treatment services be available, accessible and utilised. Affirmative actions must be taken to provide care for the most vulnerable, for those who cannot advocate for themselves. In small communities, the ill health of any group of people will impact negatively on the whole.  Health care is a human right to be delivered to the entire population without charge. Wellness as a goal is made more realistic by strengthening the provision of care at the community level.

Recommendations

Based on the review of relevant international standards of care and other “best practices” and current research into how the COVID-19 pandemic has disrupted the provision of services, the investigator makes the following set of recommendations. These recommendations are designed to improve access and utilisation of health care services for the most vulnerable people in Saint Lucia.

1. Instituting universal health care

Instituting universal health care in the public health care system will address the challenges of serving persons working in the informal economy in Saint Lucia and those persons who are uninsured by the National Insurance Corporations.

2. Training

These training programmes are low budget and the human resources exist to implement them in short order. All the programmes proposed for implementation over the next 5 years require trained people. By putting the training in place early we prepare for the programmes to come.

3. Copolad Training

Immediately and as a precursor, the Ministry of Heath should adopt the Copolad training curriculum / course offerings on drug and alcohol studies and seek innovative ways to provide training virtually. There exists at Turning Point a certified Master Trainer in the Copolad OAS/EU funded training curriculum. Their services are available to begin this important initial phase of cultivating the human resources needed to phase in the network of services listed below.

4. Evaluation training

Self-evaluation of services with the intent on increasing impact is critical if a service is to respond to the current needs of its service users. Staff should be trained in both quantitative or qualitative evaluation methodologies as both methods provide important information for evaluation, and both can improve community engagement.

5. Continuing Medical Education (CME)

Building on the strategy that has been developed under the National Healthcare Quality plan for training healthcare workers, all physicians require CME, nurses and staff of health centres to assist individuals in the community experiencing early signs of substance-induced dysfunctionality.

Require CME credit on:

• community psychiatric care,
• substance use,
• managing trauma
• harm reduction for people who use stimulants

6. Surveillance

Create a foundation of community based early detection interventions based at health centres and interconnected with community based organisations. Surveillance should be ongoing to detect changes in drug use patterns associated with the movement of people. Saint Lucia has experienced returning nationals seeking refuge from COVID-19 and immigrants seeking shelter, each bringing with them behaviours learned abroad, some associated with drug use. Migrants from countries where injecting drug use is common may find themselves in Saint Lucia.

Immigration status or documentation issues should not be an impediment to utilise treatment. It is necessary to ensure that the treatment environment is friendly, culturally sensitive and focused on the specific clinical needs and level of preparedness of each patient, which encourages rather than deters individuals from attending.

7. Legislation to regulate treatment services and providers

These recommendations for changes to legislations and policies will bring Saint Lucia into greater harmony with international standards.

Legislation is needed to regulate and codify the standards for the provision of drug and alcohol treatment services. Licensing of treatment providers and physical locations would also be included in the law and required.

Regulate the provision of drugs and alcohol services and service providers, instituting standards to improve quality health and social interventions.

Require all interventions be examined at regular intervals for compliance with the latest peer reviewed evidence.

Require a dedicated budget for the ongoing training of human resources in substance use.

Other legislation that would reduce incarceration rates and prison overcrowding

Legalise and regulate cannabis

Legalise and regulate cannabis making it available for therapeutic use.

8. Alternative Sentencing

Reduce incarceration and prison overcrowding and the potential for infectious disease spread by passing legislation to create a system of alternative sentencing, keeping non-violent offenders out of prison.

9. Reduce Remand Population

Remove bail requirements for all non-violent offences will reduce remand population and allow for prison authorities to focus on the rehabilitation of the convict population.

10. Services

A comprehensive national drug and alcohol treatment programme

The overarching recommendation is to develop and institute over the next 5 years a comprehensive national drug and alcohol treatment services. These services would include: (* denotes existing services)

• community-based outreach utilising non-specialised settings like local Wellness Centres, Community Centres where services may be provided
• inpatient psychosocial treatment at Turning Point*
• outpatient psychosocial treatment at the community level
• medical assisted alcohol detoxification in the treatment of alcohol use disorders*
• treatment for psychiatric or physical health comorbidities*
• long-term residential or community-based treatment or rehabilitation
• recovery-support services and transitional housing

Community services should:

• be free and available in both urban and rural settings
• be accessible, with a wide range of opening hours appropriate to the population
• be low threshold with minimum barriers that facilitate access to appropriate treatment services
• offer treatment for substance use disorders that includes trauma as an antecedent to substance use.
• provide social support and protection, as well as general medical care
• offers a wide variety of high- quality interventions at various levels to meet the needs of a diverse population of substance users.
• be welcoming
• partnership opportunities with civil society and community based organisations to provide an effective comprehensive drug treatment programme across the continuum.
• increase the number of social workers trained in drugs and alcohol deployed in the community.

11. Group homes

There are a number of psychiatric patients with co-occurring substance use issues living rough on the street. There needs to be group homes for those that cannot manage on their own.

12. Decentralize clinics to reduce mass travel

Clinics have moved from walk in 1^st come 1^st server to an appointment system restricting utilization for those who find making an appointment a daunting task.

Efforts should be made to move clinics on a rotating basis to community health centres to reduce exposure to COVID-19 from bus transport to Owen King EU Hospital.

13. Prison treatment

Psychosocial treatment should be on offer for all incarcerated persons. Persons on remand should be offered short term sessions to help them reflect on what brought them into prison.

Inmates should have available long term sessions, individual and group work to allow them to investigate the origins and influences that brought them to be incarcerated and how they can break out the cycle of recidivism.

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Inter-American Drug Abuse Control Commission, A report on students’ drug use in 13 Caribbean Countries : Antigua and Barbuda, The Bahamas , Barbados, Belize, Dominica, Grenada, Guyana, Haiti, Jamaica, St. Kitts and Nevis, St. Lucia, St. Vincent and the Grenadines, Trinidad and Tobago. ISBN 978-0-8270-6574-

International standards for the treatment of drug use disorders: revised edition incorporating results of field-testing. Geneva: World Health Organisation and United Nations Office on Drugs and Crime; 2020. ISBN 978-92-4-000219-7

Marczinski CA, Fillmore MT. Energy drinks mixed with alcohol: what are the risks? Nutr Rev. 2014;72(suppl 1):98–107

National Survey on Substance Abuse among Students Attending Secorndary School Saint Lucia 2005 http://www.cicad.oas.org/oid/caribbean/2007/St_%20Lucia%20School%20Survey.pdf

Neufeld, Maria & Ferreira-Borges, Carina & Monteiro, Maristela. (2020). Alcohol and COVID-19: what you need to know.

Organisation of America States (OAS). 2004. Inter-American Drug Abuse Control Commission (CICAD). Multilateral Evaluation Mechanism (MEM). Governmental Expert Group (GEG). “St. Lucia.” Evaluation of Progress in Drug Control 2003-2004.

Pan American Health Organisation, “Health Systems Services Profile Saint Lucia” Washington, D.C.: PAHO, 2010 ISBN: 978-92-75-13205-0

Poverty in Saint Lucia, Kairi Consultants Limited, 2007

Rosmarin A. & Eastwood N. A Quiet Revolution: Drug Decriminalisation Policies in Practice Across the Globe, Release, 2012, http://www.release.org.uk/publications/quiet-revolution-drug-decriminalisation-policies-practice-across-globe

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This document is extracted from an assessment of the effect of COVID-19 pandemic on the provision of drug treatment services provided by Turning Point Treatment Centre, St Lucia.

The document highlights key areas of the assessment and will complement the full document of the assessment presently under approval by the Ministry of Health.

Acknowledgement

The researcher acknowledges with gratitude the contribution of everyone who participated in the process culminating in this report. The report provides vital information on the impact which COVID-19 had on access and utilisation of drug and alcohol treatment services provided by Turning Point.

This report was prepared in collaboration with Turning Point and the Substance Use Department in the Ministry of Health St Lucia and the Pan American Health Organization.

This Assessment for Saint Lucia is a product of collaborative effort by various stakeholders:

• Government ministries and departments who facilitated consultation meetings and provided valuable information and insights which informed the situation assessment.
• Key stakeholders who were an invaluable source of information including officials from the line ministries, health care personnel, social workers, police officers, magistrates, faith-based organisations, and non-governmental organisations.

The author gratefully acknowledges the following individuals who contributed to the development of this report:

Robert Huggins

Ira A. L. Isaacs, MPH

Charmaine Hippolyte Emmanuel,

Dr Stephen King,

Allison Jean

List of Acronyms

CBO             Community-based organisation

COPD           Chronic Obstructive Pulmonary Disease

COPOLAD    Cooperation Programme between Latin America, the Caribbean                          and the European Union on Drugs Policies.

CSO             Civil society organisation

DOT             Directly Observed Therapy

HBV              Hepatitis B Virus

HCV             Hepatitis C Virus

HIV               Human immunodeficiency virus

IDU               Injecting Drug Use

MHMC          Millennium Heights Medical Complex

MSM             Gay men and other men who have sex with men

NCD             Non-communicable disease

NDC             National Drug Council

NIDU            Non-Injecting Drug Use

NGO             Non-governmental organisation

PAHO           Pan American Health Organisation

PEP              Post-exposure prophylaxis

PWUD          People who use drugs (not confined to injecting)

S&D              Stigma and discrimination

STI               Sexually transmitted infections

SUD             Substance Use Disorder

SW               Sex workers

TB                Tuberculosis

UNODC        United Nations Office on Drugs and Crime

WHO            World Health Organization

 

Terms of Reference of this research

 

1. Assess the impact of COVID 19 on the drug treatment programme, including a brief comparative analysis of this year (2020) to the previous years;

 

1. Conduct consultations with stakeholders, actors and the general public for feedback about the needs and expectations of a drug treatment centre in Saint Lucia during this pandemic and beyond;

 

• Collect data and provide the information to identify what are the barriers in the utilization and access of the addiction treatment programmes in Saint Lucia;

 

1. Assess what are the risk levels of persons who use drugs in Saint Lucia to COVID 19 and other diseases of public health interest, both communicable and non-communicable;

 

1. Review relevant legislation and policies related to the management of persons with Substance Use Disorder and the treatment of the disease. The consultant will be expected (but not limited) to:
2. a) Provide recommendations for changes to legislations and policies, as necessary.
3. b) Provide a report to inform on the development of new policies and standard operating procedures (SOPs) for all relevant stakeholders including stakeholders such as Police, Human Services and the Treatment Centre in managing PWUD.
4. Review international standards of care for detoxification, rehabilitation, and drug addiction centres to determine how well the treatment services in Saint Lucia meets those standards.

 

• Based on the review of the above international standards of care and other “best practices” during this COVID 19 pandemic, provide comprehensive recommendations to improve the effectiveness of addictions treatment in Saint Lucia, taking into consideration the legislations and policies.

 

• Plan and facilitate a one-day workshop to present the findings and recommendations of the RSA to key stakeholders for feedback. This includes the Minister of Health, Permanent Secretary, Deputy Permanent Secretary and other key personnel of the Department of Health and Wellness; the staff of Turning Point; and the Board of Directors of the Owen King European Union (OKEU) Hospital; and

 

1. Prepare and submit a final report of all the findings and recommendations as related to the above activities, taking into consideration the feedback from the one-day workshop.

 

1. Develop an Inception Report equipped with a work-plan of how the Rapid Assessment will be conducted, including plans to mitigate risks associated with the current COVID 19 pandemic during the data gathering and consultation processes;

 

1. Develop or adopt a Rapid Assessment tool to determine the levels of demand for drug treatment in Saint Lucia. This includes identifying who are the drug using populations, what drugs are they using, how they use the drugs, and the impact of the COVID-19 pandemic on the treatment programmes available;

 

• Assess the impact of COVID 19 on the drug treatment programme, including a brief comparative analysis of this year (2020) to the previous years;

 

• Conduct consultations with stakeholders, actors and the general public for feedback about the needs and expectations of a drug treatment centre in Saint Lucia during this pandemic and beyond;

 

• Collect data and provide the information to identify what are the barriers in the utilization and access of the addiction treatment programmes in Saint Lucia;

 

1. Assess what are the risk levels of persons who use drugs in Saint Lucia to COVID 19 and other diseases of public health interest, both communicable and non-communicable;

 

• Review relevant legislation and policies related to the management of persons with Substance Use Disorder and the treatment of the disease. The consultant will be expected (but not limited) to:

1. a) Provide recommendations for changes to legislations and policies, as necessary.
2. b) Provide a report to inform on the development of new policies and standard operating procedures (SOPs) for all relevant stakeholders including stakeholders such as Police, Human Services and the Treatment Centre in managing PWUD.

• Review international standards of care for detoxification, rehabilitation, and drug addiction centres to determine how well the treatment services in Saint Lucia meets those standards.

 

• Based on the review of the above international standards of care and other “best practices” during this COVID 19 pandemic, provide comprehensive recommendations to improve the effectiveness of addictions treatment in Saint Lucia, taking into consideration the legislations and policies.

 

• Plan and facilitate a one-day workshop to present the findings and recommendations of the RSA to key stakeholders for feedback. This includes the Minister of Health, Permanent Secretary, Deputy Permanent Secretary and other key personnel of the Department of Health and Wellness; the staff of Turning Point; and the Board of Directors of the Owen King European Union (OKEU) Hospital; and

 

1. Prepare and submit a final report of all the findings and recommendations as related to the above activities, taking into consideration the feedback from the one-day workshop.

 

 

[1] http://www.cicad.oas.org/oid/caribbean/2007/St_%20Lucia%20School%20Survey.pdf

[2] WHO, Coronavirus disease (COVID-19) pandemic, https://www.euro.who.int/en/health-topics/health-emergencies/coronavirus-covid-19/novel-coronavirus-2019-ncov

[3] 36 primary health care facilities for a population of 165,000

[4] Illicit abortions performed by licensed physicians are available for a fee that is outside the reach of many young women. Unwanted pregnancies could be avoided if abortions were free and available.

[5] Saint Lucia’s Drugs (Prevention of Misuse) Act http://www.oas.org/juridico/mla/en/lca/en_lca_No_22.html

[6] World Bank, Global Economic Prospects, chapter 1, page 3, June 2020,  accessed 4 Nov 2020 https://openknowledge.worldbank.org/bitstream/handle/10986/33748/211553-Ch01.pdf

[7] CDB to lend US$70 million to The Bahamas and Saint Lucia, countering the COVID-19 fallout Format News and Press Release Source CDB Posted 25 Sep 2020

https://reliefweb.int/report/bahamas/cdb-lend-us70-million-bahamas-and-saint-lucia-countering-covid-19-fallout

[8] of 44% among males aged 15 to 24 age group https://data.worldbank.org/indicator/SL.UEM.1524.MA.ZS?locations=LC&view=chart

[9] NATIONAL SURVEY ON SUBSTANCE ABUSE AMONG STUDENTS ATTENDING SECONDARY SCHOOL SAINT LUCIA 2005, http://www.cicad.oas.org/oid/caribbean/2007/St_%20Lucia%20School%20Survey.pdf

[10] alcohol 59.3%, crack cocaine 3.5%

[11] alcohol 57%, crack cocaine 11.8%

[12]   Day, M Cocaine and the Risk of HIV infection in Saint Lucia, CDARI, 2007

[13] Saint Lucia to review Public Health Act, https://stluciatimes.com/saint-lucia-to-review-and-amend-public-health-act/

[14] Simon, G. Health officials: COPD on the rise, GoSL GIS Wednesday, January 6, 2016