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A patient who has taught me a lot about how to best care for people who use drugs floored me one afternoon while she was in the clinic when I asked her thoughts on getting vaccinated against Covid-19.

“I know this sounds crazy,” she said, casting her gaze to the floor, “but I trust my drug dealer more than I trust this vaccine.”

I was stunned. Curious how anyone could trust putting something from the current fentanyl-contaminated heroin supply in their arm over a highly vetted vaccine, I had to ask, “What makes you trust your dealer?”

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Here’s the gist of what she told me: When she speaks to her dealer, they listen to her concerns without judgment and accept her for who she is. When she feels bad, they are attentive to her. They will not sell her drugs if they know she is in a bad place because they have known each other for a long time. They are highly accessible, often by text or phone at all hours. They deliver a tangible, immediate response to the needs she expresses. They have time for her and treat her like they would any other human.

To be sure, not all people who sell drugs operate in the best interest of their consumers. After all, we are currently enduring the fourth wave of the opioid overdose epidemic due to illicitly-manufactured fentanyl that has been contaminating the drug supply. Although this phenomenon should be analyzed as a potential result of the war on drugs, some sellers in the drug market clearly prioritize profits over the lives of their customers. This is highlighted by the fact that people who use drugs are more likely to die of a drug overdose than Covid-19.

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Yet my patient isn’t alone having this kind of experience with the person who sells her drugs. Other people who use drugs trust their drug dealers, especially those they have established relationships with over longer periods of time. In these sorts of relationships, people who use drugs trust that their dealer communicates openly about the drug supply. As one person told British of Columbia researchers about their dealer: “I guess we’ve known each other for a long time and they’ve always had a good supply and treat me with respect.”

Contrast this with how the health care system treats people who use drugs.

Up to 30% of people who have a substance problem leave the hospital against medical advice due to stigma and the fear of mistreatment. Even if treatment is provided, many feel forced to downplay their substance use due to fear that revealing it will result in receiving inferior care. The negative attitudes health professionals often display toward patients with substance use disorders lead to them receiving suboptimal health care.

The mistrust that people who use drugs have for the health care system is real, and it’s rooted in the many micro- and macro-aggressions the health care system inflicts on people in this marginalized group.

The Covid-19 pandemic has put a spotlight on just how vulnerable this group is. People with substance use disorders have eight times the risk of contracting Covid-19 and higher rates of death and hospitalization compared to the general population. They may also be at increased risk for breakthrough infections, which may be attributed to the higher prevalence of co-occurring chronic diseases and poor social determinants of health.

There is little information about vaccination uptake among people who use drugs, although from my experience as a provider caring for people with addiction the rate is notably low. In an interview with researchers affiliated with the Addiction Policy Forum, one person in recovery said about Covid-19 and vaccines, “I would rather catch it, I don’t trust the government. I dunno, it’s so new I don’t want to be on the receiving end of it, I’m not high risk or anything. If I did catch it, I don’t foresee it being fatal for me. I don’t get flu vaccines.”

The influenza vaccine, in line with other vaccines, also has reduced uptake among people who use drugs. Although studies have not identified why a disparity exists in taking advantage of this preventive health measure among this group compared to the general population, from my experience it appears to be rooted in distrust.

How do we combat the mistrust that people who use drugs have toward Covid-19 vaccines and the health care system at large?

Perhaps providers and public health experts can learn from my patient’s drug dealer.

Be attentive and available to people who use drugs, who distrust the health care system. Create systems of care that are accessible to them and offer them long-lasting provider relationships. Listen to their concerns without judgment and meet them where they are. Deliver an actionable, tangible response to their needs.

Simply put — treat people who use drugs like anyone else.

I saw my patient in the clinic last month, and she was warming up to the idea of receiving the vaccine to protect her family. I sent her a draft of this essay, and she sent this in response, “I haven’t seen a primary care provider (aside from you) in about a decade for fear of the way I’d be treated, never mind other doctors I probably should be seeing for my well-being. It really is a problem and unfortunately has caused more harm than it ever should.”

I read her message with a wistful grin, amused that a lesson on “do no harm” — namely, treat patients with respect — could come from a drug dealer.

Nicholaus Christian is an internal medicine physician and addiction fellow in the Yale Program in Addiction Medicine.

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