Four interrelated themes were identified in the analysis, describing how the first lockdown affected the everyday life and health of persons suffering from MHD and SUD: 1) The COVID-19 outbreak as a perceived challenge, 2) A decline in mental health and well-being, 3) Increased substance use challenges, and 4) Diverse experiences with health and social services. These themes are presented with their respective sub-themes.
Theme 1: ‘The COVID-19 outbreak as a perceived challenge’
All interviewees described the lockdown in connection with the COVID-19 outbreak as a burden and a significant challenge in their lives. The participants reported having several concerns and worries due to the pandemic. The possibly of infecting others was a great concern to everyone. They were especially afraid of infecting older people and relatives, since they felt that they were more vulnerable to COVID-19 than others and did not want to be transmitters of the disease:
“I started coughing and then I was afraid I'd got it, locked myself in for two weeks and I was so scared I'd infected them (the family).” (Marius)
Some said that they paid special attention to avoid infecting their loved ones:
“I didn't see my children because I wanted to pay attention to them, I don't want them to get infected because I live in a place like this (supported housing).” (Kari)
Another concern was being a possible burden to society if they became infected. Participants said that they did not want to bother anyone, because they felt that other people needed more help than they did themselves. One woman put it like this:
“I could have died instead of many others who’ve died, I’m just an old drug addict.” (Hilde)
On the other hand, almost none of the participants were afraid of becoming infected themselves. Some believed that drug addicts are somehow immune to COVID-19:
“I'm not worried about getting ill, maybe addicted people are more cautious than others.”
“... probably a lot of toxins in me that drive out the coronavirus.” (Thale)
They were not worried about becoming ill: “... maybe the dope kills the virus.” (Jan)
‘Relation to infection control measures’
With regard to how the informants handled the lockdown, the results are ambiguous. Some participants found strategies, such as putting oneself in quarantine, sleeping a lot or watching TV all day long, to get through the first lockdown, while others struggled to cope with even a single day. The majority reported having an understanding for the infection control measures. Most of them insisted that they followed the rules such as washing and disinfecting their hands, maintaining physical distance and having little contact with others to avoid infection:
“Those rules are for our own good. I follow the rules, but there are so many people who don't. Because you'll never be careful enough, so I feel like what I'm doing is what I can do to keep COVID away from me and my friends.” (Kari)
Most informants imposed self-quarantine on themselves and stayed indoors for the first three weeks of the lockdown. They felt it was the only thing they could do to avoid infecting others and coping with the new circumstances of the pandemic. Many experienced this self-quarantine as a state of emergency but also the only way to handle the early stage of the pandemic. Unlike the majority, one informant admitted that he tried to ignore the pandemic by living life as usual:
“I’m in contact with all my friends, we don’t care, we hang around and use the same pipe, and none of us have been infected with COVID so far.” (Jan)
Another participant, an active drug user, showed mistrust:
“I don't trust the statistics, up and down and to and fro. I think that’s not real. That helps me.” (Philip)
Jan, who was hanging out with his friends, found that ignoring the virus was the best way of handling the lockdown: “Nobody’s going to tell me what to do or not to do. I know myself what’s best for me.” (Jan)
Participants noted that keeping physical distance to others was difficult. Social gestures such as shaking hands and hugging were mentioned by both those who were clean and those using substances as an important part of social routines that usually improved their well-being. Avoiding physical contact was a great challenge for both women and men:
“Physical contact is important, it's just as important for people in the drug scene as for everyone else. Also, the sexual bit is no longer a topic since COVID.” (Thomas)
Some found themselves in a dilemma, balancing the advantages and risks of hugging a person, which was stressful:
“You have to make a choice if the hug is worth the risk, it drives me crazy.” (Tuva)
‘Positive indirect side-effects of the lockdown’
A third of the participants, i.e. those who were either clean or consumed legal substances, found out that a meaningful activity was helping them to cope with the lockdown. Some started reading books, going for walks, listening to music or playing the guitar. Several informants said that there was also something positive about the lockdown. A woman in her 50s explained proudly that she had learned to enjoy her own company. Another informant reported that taking up guitar playing made him take less drugs at a time when society was shut down:
“I played the guitar a lot because I wasn’t much with other people and drank less and smoked less because I socialised less.” (Kari)
Others mentioned that they took substances less during the first lockdown since there was little socialising with others due to the national restrictions, which they found positive. These people usually used substances while going out with peers.
Theme 2: ‘A decline in mental health and well-being’
The participants who could not find any benefit from the pandemic, which was the majority, reported having more periods of depression and anxiety during the first COVID-19 lockdown. A man in his 30s using amphetamines explained that he began self-medication due to increasing depressive episodes.
“In the beginning I was scared, thought it was the Black Death, but I'm not afraid of dying, I think it’s just really frightening. I'm living in constant fear, taking some pills to get rid of these suicidal thoughts.” (Espen)
Another man who lived in supported housing described how he would spend long periods just lying in his room, becoming more and more depressive. Mari, a woman on an OST programme, stated that her greatest challenges were tremors triggered by her concerns about the pandemic. Feeling hopeless in general and being powerless against the virus was reported to have a negative impact on participants’ mental health.
‘Perceived social exclusion’
Participants living alone in council housing were afraid of increasing social isolation, if society was shut down for a long time. It also emerged that most interviewees felt lonelier during the lockdown, although some found little difference from pre- pandemic times.
Further, many interviewees reported experiencing stigma due to their MHD/SUD. A woman mentioned an incident in a supermarket:
“People look at you especially if you obviously look like a drug addict. Someone asked me if I was a super spreader. I got so angry.” (Tuva)
Another woman found that people kept greater distance from her and referred to a conductor on the train who ignored her when she wanted to show her tickets, but checked the tickets of the other passengers. This was a humiliating experience for the informant and made her feel particularly stigmatised during COVID-19. Moreover, the loss of daily routines and structures was described as challenging for the mental health for most informants. Some were engaged in a work programme that was affected by the lockdown in March 2020. Either the programme was suspended, or the work could not be carried out as usual due to the governmental infection control regulations. A participant who normally sold a charity magazine in the pedestrian zone explained:
“When corona came, no one would buy any more magazines from me. Now I have nothing to do. I miss my work routines. It’s so meaningless.” (Kevin)
For Kevin this situation not only implied a loss of daily routine and income but he also experienced discrimination. Kevin gave the impression that nobody wanted to buy magazines from a drug addict who might spread the virus easily and said that made him feel worthless. Another participant used to clean toilets regularly, but the national lockdown put the job on hold. Although the informant said that this was not a prestigious job, he felt that it was meaningful, and the loss of this activity made him feel worthless. Further, the closed soup kitchens, meeting places and facilities aimed at persons with SUD were mentioned as affecting the mental health of the participants. Although later in the lockdown there were alternatives, such as ‘walk and talk’ (one-to-one counselling while going for a walk) or the distribution of food packages, the interviewees said that it was challenging to adapt to the new measures and they still felt distressed. Harald, a man who usually went to a soup kitchen where he could also take a shower twice a week, reported that he had no other place to go when this facility was shut down. This made him feel helpless and anxious.
Losing their social networks was a concern expressed by many participants, especially those who reported being in a recovery process. Peter explained that he had spent considerable time building his self-confidence, which helped him to join a group of Narcotics Anonymous. This network helped him to become drug-free.
“I was afraid of losing the platform I'd built up after I've been drug-free, it was frightening.” (Peter)
Little contact with other people and loss of daily routines were also grounds for concern among those who were mentally stable, as they were afraid of having a relapse of a mental health disorder.
Theme 3: ‘Increased substance use challenges’
Being lonely without a social network meant that people who were cutting down on substances or had become substance-free were afraid of a relapse. Others said they were tempted to buy alcohol or drugs to allay their fear of being alone:
“I was clean when COVID came, I’m afraid of being tempted to take more dope.” (Peter)
However, the informants who reported using illicit drugs said that they started to take drugs more frequently or in stronger doses than usual, otherwise they would not have been able to tolerate the COVID-19 situation. A woman who had stopped taking heroin became addicted again:
“I started messing with heroin in May, needed to relax a little bit.” (Elisabeth)
Further, these users reported that there was a short period early in the pandemic when cannabis and heroin were not as easily available as usual. Along with this, there was a concern among the illicit drug users that the heroin might be diluted and thus contaminated, due to the shortage of supply.
Another informant mentioned that getting high was the only thing that helped him to get through the pandemic:
“The biggest challenge was getting enough drugs. I needed something stronger than what I was used to.” (Bjørn)
Some men stated that they drank until they did not feel anything anymore, while two women mentioned that they took amphetamines for anxiety. Getting drunk or high was described as self-medication, a way to handle the COVID-19 situation.
Theme 4: ‘Diverse experiences with health and social services’
Overall, most participants reported having had less contact than usual with health and social services, or they had no contact at all during the first month of the pandemic. Several informants found that scheduled appointments with a doctor were postponed or cancelled. Two participants had planned to go to a detoxification facility, but their admission was postponed. However, the majority expressed complete understanding for these postponements. Some were offered a digital consultation as an alternative to a physical appointment, but this did not suit everyone:
“Because of my COPD I was going to the doctor but got no appointment. Then I was offered a video consultation but I refused it and then I never spoke to my GP again.” (Jens)
This also applied to another informant who described his experience with the local mental health centre: “It was shut down, but then we used video calls. I didn't like it, it didn’t feel real, but I did it anyway.” (Runar)
Furthermore, contact with social services such as the national public welfare agency (NAV) was perceived as challenging. It was mentioned several times that it was difficult to get in touch with these services as physical attendance was no longer possible. Some felt devalued because they felt they did not have enough digital expertise. One said:
"NAV is absolutely hopeless, just a digital post box, nobody picks up the phone, I feel so powerless, discouraged. I depend on these disability benefits."(Steffen)
Informants who were in an OST programme had the impression that health professionals who supplied medications were more distanced and busier at the beginning of the lockdown. They stated that the methadone was delivered on their doorstep and that nurses avoided going to clients’ homes. Participants also mentioned that the delivery times of the substitution drugs varied greatly, which was challenging for some of them.
“I get a methadone delivery every day. But they’re not coming in. I understand that they have a lot to do, but if they don’t come on time, they mess up my day.” (Mari)
All informants who were in an OST appreciated being able to continue in the programme even during the pandemic.
Half of the informants who were in contact with health and social services showed an understanding for how health professionals acted during the pandemic. They explained that they gained respect for nurses and doctors who exposed themselves to a possible COVID-19 infection.
Two participants were positively surprised to receive a call from their GP to ask how they were doing. They felt that the pandemic made health professionals more attentive:
“My doctor just showed up at the door and asked how I was doing. We sat outside and talked; it was good to be seen as a person who needs special attention.” (Harald)
The council addiction services also received a positive mention when they contacted participants proactively by phone and provided walk and talk consultations.