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Puerto Rico (U.S.) Traveler View

Travel health notices, vaccines and medicines, non-vaccine-preventable diseases, stay healthy and safe.

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After Your Trip

There are no notices currently in effect for Puerto Rico (U.S.).

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Check the vaccines and medicines list and visit your doctor at least a month before your trip to get vaccines or medicines you may need. If you or your doctor need help finding a location that provides certain vaccines or medicines, visit the Find a Clinic page.

Routine vaccines

Recommendations.

Make sure you are up-to-date on all routine vaccines before every trip. Some of these vaccines include

• Chickenpox (Varicella)
• Diphtheria-Tetanus-Pertussis
• Flu (influenza)
• Measles-Mumps-Rubella (MMR)

Immunization schedules

All eligible travelers should be up to date with their COVID-19 vaccines. Please see  Your COVID-19 Vaccination  for more information. 

COVID-19 vaccine

Hepatitis A

Recommended for unvaccinated travelers one year old or older going to Puerto Rico.

Infants 6 to 11 months old should also be vaccinated against Hepatitis A. The dose does not count toward the routine 2-dose series.

Travelers allergic to a vaccine component or who are younger than 6 months should receive a single dose of immune globulin, which provides effective protection for up to 2 months depending on dosage given.

Unvaccinated travelers who are over 40 years old, immunocompromised, or have chronic medical conditions planning to depart to a risk area in less than 2 weeks should get the initial dose of vaccine and at the same appointment receive immune globulin.

Hepatitis A - CDC Yellow Book

Dosing info - Hep A

Hepatitis B

Recommended for unvaccinated travelers of all ages traveling to Puerto Rico.

Hepatitis B - CDC Yellow Book

Dosing info - Hep B

Cases of measles are on the rise worldwide. Travelers are at risk of measles if they have not been fully vaccinated at least two weeks prior to departure, or have not had measles in the past, and travel internationally to areas where measles is spreading.

All international travelers should be fully vaccinated against measles with the measles-mumps-rubella (MMR) vaccine, including an early dose for infants 6–11 months, according to  CDC’s measles vaccination recommendations for international travel .

Measles (Rubeola) - CDC Yellow Book

Puerto Rico is free of dog rabies. However, rabies may still be present in wildlife species, particularly bats. CDC recommends rabies vaccination before travel only for people working directly with wildlife. These people may include veterinarians, animal handlers, field biologists, or laboratory workers working with specimens from mammalian species.

Rabies - CDC Yellow Book

Recommended for most travelers, especially those staying with friends or relatives or visiting smaller cities or rural areas.

Typhoid - CDC Yellow Book

Dosing info - Typhoid

Avoid contaminated water

Leptospirosis

How most people get sick (most common modes of transmission)

• Touching urine or other body fluids from an animal infected with leptospirosis
• Swimming or wading in urine-contaminated fresh water, or contact with urine-contaminated mud
• Drinking water or eating food contaminated with animal urine
• Avoid contaminated water and soil

Clinical Guidance

Avoid bug bites, african tick-bite fever.

• Avoid Bug Bites

African Tick-bite fever

• Mosquito bite
• An infected pregnant woman can spread it to her unborn baby

Airborne & droplet

• Breathing in air or accidentally eating food contaminated with the urine, droppings, or saliva of infected rodents
• Bite from an infected rodent
• Less commonly, being around someone sick with hantavirus (only occurs with Andes virus)
• Avoid rodents and areas where they live
• Avoid sick people

Tuberculosis (TB)

• Breathe in TB bacteria that is in the air from an infected and contagious person coughing, speaking, or singing.

Learn actions you can take to stay healthy and safe on your trip. Vaccines cannot protect you from many diseases in Puerto Rico, so your behaviors are important.

Eat and drink safely

Food and water standards around the world vary based on the destination. Standards may also differ within a country and risk may change depending on activity type (e.g., hiking versus business trip). You can learn more about safe food and drink choices when traveling by accessing the resources below.

• Choose Safe Food and Drinks When Traveling
• Water Treatment Options When Hiking, Camping or Traveling
• Global Water, Sanitation and Hygiene | Healthy Water
• Avoid Contaminated Water During Travel

You can also visit the  Department of State Country Information Pages  for additional information about food and water safety.

Prevent bug bites

Bugs (like mosquitoes, ticks, and fleas) can spread a number of diseases in Puerto Rico. Many of these diseases cannot be prevented with a vaccine or medicine. You can reduce your risk by taking steps to prevent bug bites.

What can I do to prevent bug bites?

• Cover exposed skin by wearing long-sleeved shirts, long pants, and hats.
• Use an appropriate insect repellent (see below).
• Use permethrin-treated clothing and gear (such as boots, pants, socks, and tents). Do not use permethrin directly on skin.
• Stay and sleep in air-conditioned or screened rooms.
• Use a bed net if the area where you are sleeping is exposed to the outdoors.

What type of insect repellent should I use?

• FOR PROTECTION AGAINST TICKS AND MOSQUITOES: Use a repellent that contains 20% or more DEET for protection that lasts up to several hours.
• Picaridin (also known as KBR 3023, Bayrepel, and icaridin)
• Oil of lemon eucalyptus (OLE) or para-menthane-diol (PMD)
• 2-undecanone
• Always use insect repellent as directed.

What should I do if I am bitten by bugs?

• Avoid scratching bug bites, and apply hydrocortisone cream or calamine lotion to reduce the itching.
• Check your entire body for ticks after outdoor activity. Be sure to remove ticks properly.

What can I do to avoid bed bugs?

Although bed bugs do not carry disease, they are an annoyance. See our information page about avoiding bug bites for some easy tips to avoid them. For more information on bed bugs, see Bed Bugs .

For more detailed information on avoiding bug bites, see Avoid Bug Bites .

Stay safe outdoors

If your travel plans in Puerto Rico include outdoor activities, take these steps to stay safe and healthy during your trip.

• Stay alert to changing weather conditions and adjust your plans if conditions become unsafe.
• Prepare for activities by wearing the right clothes and packing protective items, such as bug spray, sunscreen, and a basic first aid kit.
• Consider learning basic first aid and CPR before travel. Bring a travel health kit with items appropriate for your activities.
• If you are outside for many hours in heat, eat salty snacks and drink water to stay hydrated and replace salt lost through sweating.
• Protect yourself from UV radiation : use sunscreen with an SPF of at least 15, wear protective clothing, and seek shade during the hottest time of day (10 a.m.–4 p.m.).
• Be especially careful during summer months and at high elevation. Because sunlight reflects off snow, sand, and water, sun exposure may be increased during activities like skiing, swimming, and sailing.
• Very cold temperatures can be dangerous. Dress in layers and cover heads, hands, and feet properly if you are visiting a cold location.

Stay safe around water

• Swim only in designated swimming areas. Obey lifeguards and warning flags on beaches.
• Practice safe boating—follow all boating safety laws, do not drink alcohol if driving a boat, and always wear a life jacket.
• Do not dive into shallow water.
• Do not swim in freshwater in developing areas or where sanitation is poor.
• Avoid swallowing water when swimming. Untreated water can carry germs that make you sick.
• To prevent infections, wear shoes on beaches where there may be animal waste.

Schistosomiasis, a parasitic infection that can be spread in fresh water, is found in Puerto Rico. Avoid swimming in fresh, unchlorinated water, such as lakes, ponds, or rivers.

Keep away from animals

Most animals avoid people, but they may attack if they feel threatened, are protecting their young or territory, or if they are injured or ill. Animal bites and scratches can lead to serious diseases such as rabies.

Follow these tips to protect yourself:

• Do not touch or feed any animals you do not know.
• Do not allow animals to lick open wounds, and do not get animal saliva in your eyes or mouth.
• Avoid rodents and their urine and feces.
• Traveling pets should be supervised closely and not allowed to come in contact with local animals.
• If you wake in a room with a bat, seek medical care immediately. Bat bites may be hard to see.

All animals can pose a threat, but be extra careful around dogs, bats, monkeys, sea animals such as jellyfish, and snakes. If you are bitten or scratched by an animal, immediately:

• Wash the wound with soap and clean water.
• Go to a doctor right away.
• Tell your doctor about your injury when you get back to the United States.

Consider buying medical evacuation insurance. Rabies is a deadly disease that must be treated quickly, and treatment may not be available in some countries.

Reduce your exposure to germs

Follow these tips to avoid getting sick or spreading illness to others while traveling:

• Wash your hands often, especially before eating.
• If soap and water aren’t available, clean hands with hand sanitizer (containing at least 60% alcohol).
• Don’t touch your eyes, nose, or mouth. If you need to touch your face, make sure your hands are clean.
• Cover your mouth and nose with a tissue or your sleeve (not your hands) when coughing or sneezing.
• Try to avoid contact with people who are sick.
• If you are sick, stay home or in your hotel room, unless you need medical care.

Avoid sharing body fluids

Diseases can be spread through body fluids, such as saliva, blood, vomit, and semen.

Protect yourself:

• Use latex condoms correctly.
• Do not inject drugs.
• Limit alcohol consumption. People take more risks when intoxicated.
• Do not share needles or any devices that can break the skin. That includes needles for tattoos, piercings, and acupuncture.
• If you receive medical or dental care, make sure the equipment is disinfected or sanitized.

Know how to get medical care while traveling

Plan for how you will get health care during your trip, should the need arise:

• Carry a list of local doctors and hospitals at your destination.
• Review your health insurance plan to determine what medical services it would cover during your trip. Consider purchasing travel health and medical evacuation insurance.
• Carry a card that identifies, in the local language, your blood type, chronic conditions or serious allergies, and the generic names of any medications you take.
• Some prescription drugs may be illegal in other countries. Call Puerto Rico’s embassy to verify that all of your prescription(s) are legal to bring with you.
• Bring all the medicines (including over-the-counter medicines) you think you might need during your trip, including extra in case of travel delays. Ask your doctor to help you get prescriptions filled early if you need to.

Many foreign hospitals and clinics are accredited by the Joint Commission International. A list of accredited facilities is available at their website ( www.jointcommissioninternational.org ).

In some countries, medicine (prescription and over-the-counter) may be substandard or counterfeit. Bring the medicines you will need from the United States to avoid having to buy them at your destination.

Select safe transportation

Motor vehicle crashes are the #1 killer of healthy US citizens in foreign countries.

In many places cars, buses, large trucks, rickshaws, bikes, people on foot, and even animals share the same lanes of traffic, increasing the risk for crashes.

Be smart when you are traveling on foot.

• Use sidewalks and marked crosswalks.
• Pay attention to the traffic around you, especially in crowded areas.
• Remember, people on foot do not always have the right of way in other countries.

Riding/Driving

Choose a safe vehicle.

• Choose official taxis or public transportation, such as trains and buses.
• Ride only in cars that have seatbelts.
• Avoid overcrowded, overloaded, top-heavy buses and minivans.
• Avoid riding on motorcycles or motorbikes, especially motorbike taxis. (Many crashes are caused by inexperienced motorbike drivers.)
• Choose newer vehicles—they may have more safety features, such as airbags, and be more reliable.
• Choose larger vehicles, which may provide more protection in crashes.

Think about the driver.

• Do not drive after drinking alcohol or ride with someone who has been drinking.
• Consider hiring a licensed, trained driver familiar with the area.
• Arrange payment before departing.

Follow basic safety tips.

• Wear a seatbelt at all times.
• Sit in the back seat of cars and taxis.
• When on motorbikes or bicycles, always wear a helmet. (Bring a helmet from home, if needed.)
• Avoid driving at night; street lighting in certain parts of Puerto Rico may be poor.
• Do not use a cell phone or text while driving (illegal in many countries).
• Travel during daylight hours only, especially in rural areas.
• If you choose to drive a vehicle in Puerto Rico, learn the local traffic laws and have the proper paperwork.
• Get any driving permits and insurance you may need. Get an International Driving Permit (IDP). Carry the IDP and a US-issued driver's license at all times.
• Check with your auto insurance policy's international coverage, and get more coverage if needed. Make sure you have liability insurance.
• Avoid using local, unscheduled aircraft.
• If possible, fly on larger planes (more than 30 seats); larger airplanes are more likely to have regular safety inspections.
• Try to schedule flights during daylight hours and in good weather.

Medical Evacuation Insurance

If you are seriously injured, emergency care may not be available or may not meet US standards. Trauma care centers are uncommon outside urban areas. Having medical evacuation insurance can be helpful for these reasons.

Helpful Resources

Road Safety Overseas (Information from the US Department of State): Includes tips on driving in other countries, International Driving Permits, auto insurance, and other resources.

The Association for International Road Travel has country-specific Road Travel Reports available for most countries for a minimal fee.

Maintain personal security

Use the same common sense traveling overseas that you would at home, and always stay alert and aware of your surroundings.

Before you leave

• Research your destination(s), including local laws, customs, and culture.
• Monitor travel advisories and alerts and read travel tips from the US Department of State.
• Enroll in the Smart Traveler Enrollment Program (STEP) .
• Leave a copy of your itinerary, contact information, credit cards, and passport with someone at home.
• Pack as light as possible, and leave at home any item you could not replace.

While at your destination(s)

• Carry contact information for the nearest US embassy or consulate .
• Carry a photocopy of your passport and entry stamp; leave the actual passport securely in your hotel.
• Follow all local laws and social customs.
• Do not wear expensive clothing or jewelry.
• Always keep hotel doors locked, and store valuables in secure areas.
• If possible, choose hotel rooms between the 2nd and 6th floors.

Healthy Travel Packing List

Use the Healthy Travel Packing List for Puerto Rico (U.S.) for a list of health-related items to consider packing for your trip. Talk to your doctor about which items are most important for you.

Why does CDC recommend packing these health-related items?

It’s best to be prepared to prevent and treat common illnesses and injuries. Some supplies and medicines may be difficult to find at your destination, may have different names, or may have different ingredients than what you normally use.

If you are not feeling well after your trip, you may need to see a doctor. If you need help finding a travel medicine specialist, see Find a Clinic . Be sure to tell your doctor about your travel, including where you went and what you did on your trip. Also tell your doctor if you were bitten or scratched by an animal while traveling.

For more information on what to do if you are sick after your trip, see Getting Sick after Travel .

Map Disclaimer - The boundaries and names shown and the designations used on maps do not imply the expression of any opinion whatsoever on the part of the Centers for Disease Control and Prevention concerning the legal status of any country, territory, city or area or of its authorities, or concerning the delimitation of its frontiers or boundaries. Approximate border lines for which there may not yet be full agreement are generally marked.

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Puerto Rico is now open to fully vaccinated Americans

And anyone else willing to get tested.

It just got a little easier to travel to  Puerto Rico  this summer. As of May 25, fully vaccinated Americans do not need to get tested before they travel to the island. And  Puerto Rico's status as a U.S. territory means that you won't have to provide a negative test to return to the mainland either. 

If you do head out to the island, all travelers over the age of two are still required to fill out a Travel Declaration Form through the Puerto Rico Health Department’s  online portal .  Fully vaccinated travelers must also upload their proof of vaccination card to the portal. You'll then receive a QR code which will be scanned at the airport upon arrival.

If you're coming from anywhere that's not the United States, you're not banned from an island vacation. You'll just need to  show proof of a negative PCR molecular COVID-19 test (nasal or throat swab) taken no more than 72 hours before arrival, and obtain an airport exit confirmation number— which will automatically be sent when the test results are uploaded to the online portal. 

Unvaccinated tourists arriving in Luis Muñoz Marín International Airport (SJU), may also have the option to receive a Johnson and Johnson vaccine in Terminal B.

Puerto Rico's island-wide rules have also relaxed slightly in time for summer: Non-essential businesses such as museums, hotel pools, restaurants and retail have increased to 50 percent capacity; fully vaccinated individuals no longer need to wear masks in parks and beaches; and alcohol is allowed in parks and beaches again. However, bars and nightclubs remain closed and some businesses may still require a negative test result upon entry. 

Despite its reopening plan, Puerto Rico is currently labeled as a Level 4 risk by the CDC, the highest level possible. While cases have been on the decline since January, the organization is still recommending against all travel here. 

Still thinking about heading on an island vacation this year?  See all the Caribbean countries that are currently open for tourism.

Remember, many countries (including the USA) are still warning against all non-essential travel and some are quarantining all overseas arrivals, including their own returning citizens. Check all the relevant restrictions before you think about traveling.

• Sarah Medina Travel Editor, North America

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Puerto Rico Drops All COVID Restrictions for Travelers Arriving on Domestic Flights

As of march 10, u.s. travelers no longer need to provide proof of vaccination or a negative covid-19 test result to enter the u.s. territory. here’s what else you need to know to visit puerto rico safely and respectfully..

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Travel to Puerto Rico just got a lot simpler.

Photo by Shutterstock

Starting March 10, 2022, travelers no longer need to present proof of vaccination or a negative COVID-19 test result to travel to Puerto Rico if they are arriving on a domestic flight from the U.S. mainland. Travelers arriving on international flights must follow the U.S. Centers for Disease Control and Prevention’s requirement to show proof of vaccination (one or two doses, finished at least 14 days prior, booster not required) and present a negative COVID-19 test taken within one day of departure.

Also as of March 10, there are no longer capacity limits or a requirement to show proof of vaccination status or a negative COVID-19 test for entrance at any restaurant, bar, theater, event venue, and beyond. Masks are no longer mandatory on the island; however, they are recommended for situations where “ vaccination status cannot be guaranteed .” Still, individual establishments may establish their own mask requirements and safety guidelines, such as proof of vaccination.

Here’s what else you need to know about traveling safely and responsibly in Puerto Rico right now.

Is Puerto Rico open for travel?

If you’re an American traveler coming from the mainland United States, yes.

If you’re traveling internationally, it’s open, but there are rules. Per Discover Puerto Rico, the official tourism organization of the island, all travelers above age two arriving on international flights must present a negative PCR or antigen COVID-19 test taken a day before departure and have proof of vaccination.

Unvaccinated travelers arriving on international flights will only be allowed in if they are U.S. citizens.

What travel restrictions are in place to go to Puerto Rico?

As of March 10, travelers arriving on domestic flights from the mainland United States are no longer required to present a vaccination card or negative COVID-19 test results.

If a traveler tests positive while in Puerto Rico, they will be required to quarantine and cover their own medical and extended stay expenses until the Health Department releases them. Those who want to be released from quarantine will have to undergo a test and share the negative results with the government. Those who break quarantine orders will be fined up to $5,000 for the first offense and up to $10,000 for any additional offenses.

Are COVID-19 tests required to return to the mainland United States from Puerto Rico?

No. As a U.S. territory, Puerto Rico is excluded from the new CDC order that requires all international passengers flying into the United States—including returning U.S. citizens—to provide proof of a negative COVID-19 test prior to boarding.

However, the CDC still recommends that unvaccinated people get tested one to three days before traveling back from Puerto Rico. Upon returning home, the CDC also recommends self-quarantining for five days and getting tested three to five days after travel. The CDC asks that vaccinated travelers self-monitor for COVID-19 symptoms and isolate and get tested if any develop after their trip.

What airlines have flights to Puerto Rico right now?

Because Puerto Rico never closed its borders, major U.S. airlines continued to fly to and from the island. However, in order to better track people arriving in Puerto Rico, between March 2020 and April 2021, flights were only allowed in and out of San Juan’s Luis Muñoz Marín International Airport.

Rafael Hernández Airport in Aguadilla (BQN) and the Mercedita International Airport in Ponce (PSE) reopened to passenger travel on April 1, 2021 . As of March 10, 2022, airlines flying to Puerto Rico’s airports include American, Delta, Frontier, Spirit, Southwest, and United, among others.

How much is actually open in Puerto Rico?

While there used to be an island-wide curfew, capacity limits for businesses, and a mask mandate for both indoors and outdoors, as of March 10, there are no limitations. In other words, everything is open.

Where to stay in Puerto Rico

Many hotels in Puerto Rico stayed open throughout the pandemic for displaced travelers and frontline workers and reopened to local leisure travelers starting in June 2020. Because some businesses are requiring proof of vaccination or negative test results upon arrival, check with your hotel to learn what their protocols are before booking.

The Hyatt Regency Grand Reserve Puerto Rico reopened for nonessential stays on June 2, 2020. In addition to implementing social-distancing measures like touchless check-in and check-out services per Hyatt’s Global Care and Cleanliness Commitment , Hyatt also installed UV light purifying air conditioners in all 579 rooms on the property.

Dorado Beach, a Ritz-Carlton Reserve reopened on July 1, 2020. The mostly open-air property is set right on the northern coast of Puerto Rico, a 35-minute drive from San Juan’s Luis Muñoz Marín International Airport. Many of the hotel’s 115 guest rooms come with direct beach access and private plunge pools, making it easier to social distance and limit indoor interactions with other guests. As a Marriott property, Dorado Beach is following health and safety protocols in accordance with Marriott’s Global Cleanliness Council.

The Associated Press contributed to this article. This article originally appeared online in June 2020; it was updated on May 24, 2021, on May 25, 2021, and again on March 10, 2022, to include current information.

>> Next: The AFAR Guide to Puerto Rico

Puerto Rico to drop COVID-related entry requirements for US travelers

Puerto Rico this week is dropping   nearly all travel-related COVID-19 restrictions for domestic travelers from the U.S. as case counts on the island continue to fall.  

Starting Thursday, domestic visitors from the U.S. will no longer need to show proof of vaccination or a negative coronavirus test to enter. 

Masks will no longer be required in indoor or outdoor venues, with some exceptions, Governor Pedro Pierluisi  announced Monday . Certain areas, such as health facilities, will still require face coverings.  

Officials recommend that people continue to wear masks indoors when the vaccination status of others is unknown. Travelers will also still need to wear a mask on the plane ride to Puerto Rico because the U.S. federal mask mandate is in effect until at least March 18. 

MASK MANDATE ON PLANES: Yes, masks are still required on planes and at airports despite new CDC mask guidelines

Learn more: Best travel insurance

Puerto Rico is also lifting all capacity restrictions. Currently, certain indoor venues like restaurants, bars, theaters and stadiums must cap capacity at 75%.   The Health Department will continue to issue special protocols for events with more than 1,000 attendees.  

Additionally, businesses like restaurants and bars will no longer need to screen customers for proof of vaccination or a negative coronavirus test before allowing entry.

"Individual establishments reserve the right to implement their own requirements surrounding masks and COVID-19 protocols, and visitors are encouraged to contact businesses directly," reads a statement from the destination marketing organization Discover Puerto Rico. 

Travelers will no longer need to fill out a travel declaration form – which included information on their vaccination status or coronavirus test results – before exiting the airport in Puerto Rico.   Airports will continue to offer centers for voluntary coronavirus testing.

Most travelers entering from outside the U.S. will still need to show proof of vaccination to enter the U.S. territory. 

Reported COVID-19 cases in Puerto Rico have been declining since early January, and the island is now reporting a seven-day average of fewer than 250 cases a day – a fraction of the 10,000-plus reported at the beginning of the year, according to data from Johns Hopkins University . 

Follow USA TODAY reporter Bailey Schulz on Twitter: @bailey_schulz . 

Puerto Rico

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Entry Requirements and Customs in Puerto Rico

Entering Puerto Rico During the Covid-19 Pandemic

In response to the global coronavirus pandemic, Puerto Rico has established the following rules for entering the island:

Each visitor must complete the Travel Declaration Form via the government's online portal .

Fully vaccinated travelers entering via domestic flights (from the U.S. mainland) will need to upload copies of their vaccination cards . Those travelers are not required to submit Covid-19 test results.  

Each unvaccinated or international visitor  must submit negative results from a PCR or antigen test  taken no more than 72 hours prior to visiting the island. Those who arrive without having uploaded results will receive a $300 fine. 

Because Puerto Rico is a U.S. territory, American citizens who visit the island are exempt from the CDC requirement to provide negative Covid-19 test results before returning to the mainland .  

For a complete rundown of Puerto Rico's entry requirements and safety restrictions while on the island, visit the official tourism site,  DiscoverPuertoRico.com .  

And for a helpful overview of pandemic travel rules in Puerto Rico and other Caribbean destinations, visit Frommer's frequently updated resources page . 

U.S. citizens coming from mainland destinations do not need passports to enter Puerto Rico. However, it is necessary to produce a government-issued photo ID to board a plane.

Visitors from other countries, including Canada, need a valid passport to land in Puerto Rico. For those from countries requiring a visa to enter the U.S., the same visa is necessary to enter Puerto Rico.

It is advised to always have at least one or two consecutive blank pages in your passport to allow space for visas and stamps that need to appear together. It is also important to note when your passport expires. Many countries require your passport to have at least 6 months left before its expiration in order to allow you into the destination.

Passport Office Links for Select English-Speaking Countries

• Australian Passport Office (tel. 131-232 )
• Canada Travel and Tourism Services
• Ireland Passports  
• New Zealand   Online Passport Service  (tel. 0800/225-050 )
• United Kingdom Passports   (tel. 0300/222-0000 )
• United States Passports

The U.S. Department of State has a Visa Waiver Program (VWP) allowing citizens of participating countries to enter the United States without a visa for stays of up to 90 days. To find a list of participating countries and other info about the program, visit the website of the U.S. State Department .  

Citizens of all other countries must have 1) a valid passport that expires at least 6 months later than the scheduled end of the visit to the U.S. and 2) a tourist visa.

For information about U.S. visas, go to travel.state.gov .

U.S. citizens do not need to clear Puerto Rican Customs upon arrival by plane or ship from the U.S. mainland.

International travelers should consult the official website of U.S. Customs and Border Protection for information on what can be brought into Puerto Rico.  

Before departing the island, U.S.-bound travelers must have their luggage inspected by the U.S. Department of Agriculture due to laws that prohibit bringing fruits and plants to the U.S. mainland. Otherwise, you can bring back as many purchased goods as you want without paying duty.

For information on what non-U.S. citizens can bring home from Puerto Rico, be sure to check with your home country. Some helpful links for several English-speaking nations:

• Australia :  abf.gov.au  (click "Entering and leaving Australia")

• Canada :   cbsa-asfc.gc.ca

• New Zealand : customs.govt.nz

• United Kingdom :   gov.uk

Medical Requirements

If you have a medical condition that requires syringe-administered medications, carry a valid signed prescription from your physician; syringes in carry-on baggage will be inspected. Insulin in any form should have the proper pharmaceutical documentation. If you have a disease that requires treatment with narcotics, you should also carry documented proof with you—smuggling narcotics aboard a plane carries severe penalties in the U.S.

Note : This information was accurate when it was published, but can change without notice. Please be sure to confirm all rates and details directly with the companies in question before planning your trip.

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COVID-19: travel health notice for all travellers

Puerto Rico travel advice

Latest updates: The Health section was updated - travel health information (Public Health Agency of Canada)

Last updated: April 15, 2024 13:01 ET

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Safety and security, entry and exit requirements, laws and culture, natural disasters and climate, puerto rico - take normal security precautions.

Take normal security precautions in Puerto Rico

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Petty crime, such as pickpocketing and purse snatching, are prevalent. Violent crime also occurs.

Ensure that your belongings, including your passports and other travel documents, are secure at all times.

Demonstrations

Demonstrations occur from time to time. Even peaceful demonstrations can turn violent at any time. They can also lead to disruptions to traffic and public transportation.

• Avoid areas where demonstrations and large gatherings are taking place
• Follow the instructions of local authorities
• Monitor local media for information on ongoing demonstrations

Mass gatherings (large-scale events)

Women’s safety

Women travelling alone may be subject to some forms of harassment and verbal abuse.

Advice for women travellers

Power and telecommunications outages

Puerto Rico experiences frequent disruptions to power and telecommunications services after Hurricane Maria destroyed much of the power grid in 2017.

Water activities

Coastal waters can be dangerous. Riptides are common.

• Consult residents and tour operators for information on possible hazards and safe swimming areas
• Follow the instructions and warnings of local authorities

If you participate in water sports, such as diving:

• choose a well-established and reputable company that has insurance
• ensure that your travel insurance covers the recreational activities you choose

If in doubt concerning the safety of the facilities or equipment, don’t use them.

Water safety abroad

Adventure tourism

If you engage in adventure tourism:

• never do so alone
• always hire an experienced guide from a reputable company
• buy travel insurance that includes helicopter rescue and medical evacuation
• ensure that your physical condition is good enough to meet the challenges of your activity
• ensure that you’re properly equipped
• ensure that you’re well informed about weather and other conditions that may pose a hazard
• inform a family member or friend of your itinerary obtain detailed information on each activity before setting out

Road safety

Road conditions and road safety vary greatly throughout the island.

Drivers may be aggressive, and few use their signals. There is heavy traffic in larger centres, particularly San Juan.

Roads in mountain areas can be narrow, winding, and poorly paved.

Public transportation

Bus and light rail services.

Bus and light rail (Tren Urbano) services are available in the metropolitan San Juan area.

Ferries travel to and from the islands of Culebra and Vieques, as well as the Dominican Republic.

Taxis are widely available. Fares are metered, except for major tourist destinations in San Juan, where they are fixed. Tourist taxis are white and have a “Taxi Turístico” label on the door.

We do not make assessments on the compliance of foreign domestic airlines with international safety standards.

Information about foreign domestic airlines

Every country or territory decides who can enter or exit through its borders. The Government of Canada can’t intervene on your behalf if you don’t meet your destination’s entry or exit requirements.

Puerto Rico is a territory of the United States. We have obtained the information on this page from the American authorities. It can, however, change at any time.

Confirm entry, exit and visa requirements prior to travelling:

• Entry and exit requirements for the United States
• U.S. Customs and Border Protection
• U.S. Embassy and Consulates

Entry requirements vary depending on the type of passport you use for travel.

Before you travel, check with your transportation company about passport requirements. Its rules on passport validity may be more stringent than the country’s entry rules.

Regular Canadian passport

Your passport must be valid for the duration of your stay.

Passport for official travel

Different entry rules may apply.

Official travel

Passport with “X” gender identifier

While the Government of Canada issues passports with an “X” gender identifier, it cannot guarantee your entry or transit through other countries. You might face entry restrictions in countries that do not recognize the “X” gender identifier. Before you leave, check with the closest foreign representative for your destination.

Other travel documents

Different entry rules may apply when travelling with a temporary passport or an emergency travel document. Before you leave, check with the closest foreign representative for your destination.

Useful links

• Foreign Representatives in Canada
• Canadian passports

Other entry requirements

Customs officials may ask you to show them a return or onward ticket and proof of sufficient funds to cover the cost of your stay.

Children and travel

Learn more about travelling with children .

Yellow fever

Learn about potential entry requirements related to yellow fever (vaccines section).

Relevant Travel Health Notices

• Global Measles Notice - 13 March, 2024
• Zika virus: Advice for travellers - 31 August, 2023
• COVID-19 and International Travel - 13 March, 2024
• Dengue: Advice for travellers - 8 April, 2024

This section contains information on possible health risks and restrictions regularly found or ongoing in the destination. Follow this advice to lower your risk of becoming ill while travelling. Not all risks are listed below.

Consult a health care professional or visit a travel health clinic preferably 6 weeks before you travel to get personalized health advice and recommendations.

Routine vaccines

Be sure that your  routine vaccinations , as per your province or territory , are up-to-date before travelling, regardless of your destination.

Some of these vaccinations include measles-mumps-rubella (MMR), diphtheria, tetanus, pertussis, polio, varicella (chickenpox), influenza and others.

Pre-travel vaccines and medications

You may be at risk for preventable diseases while travelling in this destination. Talk to a travel health professional about which medications or vaccines may be right for you, based on your destination and itinerary. 

Yellow fever is a disease caused by a flavivirus from the bite of an infected mosquito.

Travellers get vaccinated either because it is required to enter a country or because it is recommended for their protection.

• There is no risk of yellow fever in this country.

Country Entry Requirement*

• Proof of vaccination is not required to enter this country.

Recommendation

• Vaccination is not recommended.

* It is important to note that country entry requirements may not reflect your risk of yellow fever at your destination. It is recommended that you contact the nearest diplomatic or consular office of the destination(s) you will be visiting to verify any additional entry requirements.

About Yellow Fever

Yellow Fever Vaccination Centres in Canada

There is a risk of hepatitis A in this destination. It is a disease of the liver. People can get hepatitis A if they ingest contaminated food or water, eat foods prepared by an infectious person, or if they have close physical contact (such as oral-anal sex) with an infectious person, although casual contact among people does not spread the virus.

Practise  safe food and water precautions and wash your hands often. Vaccination is recommended for all travellers to areas where hepatitis A is present.

Measles is a highly contagious viral disease. It can spread quickly from person to person by direct contact and through droplets in the air.

Anyone who is not protected against measles is at risk of being infected with it when travelling internationally.

Regardless of where you are going, talk to a health care professional before travelling to make sure you are fully protected against measles.

  Hepatitis B is a risk in every destination. It is a viral liver disease that is easily transmitted from one person to another through exposure to blood and body fluids containing the hepatitis B virus.  Travellers who may be exposed to blood or other bodily fluids (e.g., through sexual contact, medical treatment, sharing needles, tattooing, acupuncture or occupational exposure) are at higher risk of getting hepatitis B.

Hepatitis B vaccination is recommended for all travellers. Prevent hepatitis B infection by practicing safe sex, only using new and sterile drug equipment, and only getting tattoos and piercings in settings that follow public health regulations and standards.

Coronavirus disease (COVID-19) is an infectious viral disease. It can spread from person to person by direct contact and through droplets in the air.

It is recommended that all eligible travellers complete a COVID-19 vaccine series along with any additional recommended doses in Canada before travelling. Evidence shows that vaccines are very effective at preventing severe illness, hospitalization and death from COVID-19. While vaccination provides better protection against serious illness, you may still be at risk of infection from the virus that causes COVID-19. Anyone who has not completed a vaccine series is at increased risk of being infected with the virus that causes COVID-19 and is at greater risk for severe disease when travelling internationally.

Before travelling, verify your destination’s COVID-19 vaccination entry/exit requirements. Regardless of where you are going, talk to a health care professional before travelling to make sure you are adequately protected against COVID-19.

 The best way to protect yourself from seasonal influenza (flu) is to get vaccinated every year. Get the flu shot at least 2 weeks before travelling.  

 The flu occurs worldwide. 

•  In the Northern Hemisphere, the flu season usually runs from November to   April.
•  In the Southern Hemisphere, the flu season usually runs between April and   October.
•  In the tropics, there is flu activity year round. 

The flu vaccine available in one hemisphere may only offer partial protection against the flu in the other hemisphere.

The flu virus spreads from person to person when they cough or sneeze or by touching objects and surfaces that have been contaminated with the virus. Clean your hands often and wear a mask if you have a fever or respiratory symptoms.

In this destination, rabies  may be present in some wildlife species, including bats. Rabies is a deadly disease that spreads to humans primarily through bites or scratches from an infected animal. 

If you are bitten or scratched by an animal while travelling, immediately wash the wound with soap and clean water and see a health care professional. 

Before travel, discuss rabies vaccination with a health care professional. It may be recommended for travellers who will be working directly with wildlife. 

Safe food and water precautions

Many illnesses can be caused by eating food or drinking beverages contaminated by bacteria, parasites, toxins, or viruses, or by swimming or bathing in contaminated water.

• Learn more about food and water precautions to take to avoid getting sick by visiting our eat and drink safely abroad page. Remember: Boil it, cook it, peel it, or leave it!
• Avoid getting water into your eyes, mouth or nose when swimming or participating in activities in freshwater (streams, canals, lakes), particularly after flooding or heavy rain. Water may look clean but could still be polluted or contaminated.
• Avoid inhaling or swallowing water while bathing, showering, or swimming in pools or hot tubs. 

Typhoid   is a bacterial infection spread by contaminated food or water. Risk is higher among children, travellers going to rural areas, travellers visiting friends and relatives or those travelling for a long period of time.

Travellers visiting regions with a risk of typhoid, especially those exposed to places with poor sanitation, should speak to a health care professional about vaccination.  

Insect bite prevention

Many diseases are spread by the bites of infected insects such as mosquitoes, ticks, fleas or flies. When travelling to areas where infected insects may be present:

• Use insect repellent (bug spray) on exposed skin
• Cover up with light-coloured, loose clothes made of tightly woven materials such as nylon or polyester
• Minimize exposure to insects
• Use mosquito netting when sleeping outdoors or in buildings that are not fully enclosed

To learn more about how you can reduce your risk of infection and disease caused by bites, both at home and abroad, visit our insect bite prevention page.

Find out what types of insects are present where you’re travelling, when they’re most active, and the symptoms of the diseases they spread.

There is a risk of chikungunya in this country.  The risk may vary between regions of a country.  Chikungunya is a virus spread through the bite of an infected mosquito. Chikungunya can cause a viral disease that typically causes fever and pain in the joints. In some cases, the joint pain can be severe and last for months or years.

Protect yourself from mosquito bites at all times. There is no vaccine available for chikungunya.

• In this country,   dengue  is a risk to travellers. It is a viral disease spread to humans by mosquito bites.
• Dengue can cause flu-like symptoms. In some cases, it can lead to severe dengue, which can be fatal.
• The level of risk of dengue changes seasonally, and varies from year to year. The level of risk also varies between regions in a country and can depend on the elevation in the region.
• Mosquitoes carrying dengue typically bite during the daytime, particularly around sunrise and sunset.
• Protect yourself from mosquito bites . There is no vaccine or medication that protects against dengue.

Zika virus is a risk in this country. 

Zika virus is primarily spread through the bite of an infected mosquito. It can also be sexually transmitted. Zika virus can cause serious birth defects.

During your trip:

• Prevent mosquito bites at all times.
• Use condoms correctly or avoid sexual contact, particularly if you are pregnant.

If you are pregnant or planning a pregnancy, you should discuss the potential risks of travelling to this destination with your health care provider. You may choose to avoid or postpone travel. 

For more information, see Zika virus: Pregnant or planning a pregnancy.

Animal precautions

Some infections, such as rabies and influenza, can be shared between humans and animals. Certain types of activities may increase your chance of contact with animals, such as travelling in rural or forested areas, camping, hiking, and visiting wet markets (places where live animals are slaughtered and sold) or caves.

Travellers are cautioned to avoid contact with animals, including dogs, livestock (pigs, cows), monkeys, snakes, rodents, birds, and bats, and to avoid eating undercooked wild game.

Closely supervise children, as they are more likely to come in contact with animals.

Person-to-person infections

Stay home if you’re sick and practise proper cough and sneeze etiquette , which includes coughing or sneezing into a tissue or the bend of your arm, not your hand. Reduce your risk of colds, the flu and other illnesses by:

•   washing your hands often
• avoiding or limiting the amount of time spent in closed spaces, crowded places, or at large-scale events (concerts, sporting events, rallies)
• avoiding close physical contact with people who may be showing symptoms of illness 

Sexually transmitted infections (STIs) , HIV , and mpox are spread through blood and bodily fluids; use condoms, practise safe sex, and limit your number of sexual partners. Check with your local public health authority pre-travel to determine your eligibility for mpox vaccine.  

Medical services and facilities

Good health care is available but conditions may vary throughout the island.

Ensure you have sufficient medication for your stay and extra in case of emergency. It can be difficult to get prescriptions refilled.

Medical evacuation can be very expensive and you may need it in case of serious illness or injury.

Make sure you get travel insurance that includes coverage for medical evacuation and hospital stays.

Travel health and safety

Keep in Mind...

The decision to travel is the sole responsibility of the traveller. The traveller is also responsible for his or her own personal safety.

Be prepared. Do not expect medical services to be the same as in Canada. Pack a   travel health kit , especially if you will be travelling away from major city centres.

You must abide by local laws.

Learn about what you should do and how we can help if you are arrested or detained abroad .

Penalties for possession, use or trafficking of illegal drugs are severe. Convicted offenders can expect jail sentences and heavy fines.

Drugs, alcohol and travel

Dual citizenship

Dual citizenship is legally recognized in the United States.

If you are a Canadian citizen, but also a citizen of the United States, our ability to offer you consular services may be limited while you're there. You may also be subject to different  entry/exit requirements .

• General information for travellers with dual citizenship
• Dual Nationality  - U.S. Department of State, Bureau of Consular Affairs

International Child Abduction

The Hague Convention on the Civil Aspects of International Child Abduction is an international treaty. It can help parents with the return of children who have been removed to or retained in certain countries in violation of custody rights. The convention applies between Canada and the United States.

If your child was wrongfully taken to, or is being held in Puerto Rico, and if the applicable conditions are met, you may apply for the return of your child to the Puerto Rican court.

If you are in this situation:

• act as quickly as you can
• contact the Central Authority for your province or territory of residence for information on starting an application under The Hague Convention
• consult a lawyer in Canada and in Puerto Rico to explore all the legal options for the return of your child
• report the situation to the nearest Canadian government office abroad or to the Vulnerable Children’s Consular Unit at Global Affairs Canada by calling the Emergency Watch and Response Centre

If your child was removed from a country other than Canada, consult a lawyer to determine if The Hague Convention applies.

Be aware that Canadian consular officials cannot interfere in private legal matters or in another country’s judicial affairs.

• List of Canadian Central Authorities for the Hague Convention
• International Child Abduction: A Guidebook for Left-Behind Parents
• Travelling with children
• The Hague Convention - Hague Conference on Private International Law
• Canadian embassies and consulates by destination
• Emergency Watch and Response Centre

You can drive in Puerto Rico with a valid Canadian driver’s licence for up to 90 days. If you plan to stay longer, you must obtain a Puerto Rican licence.

The currency of Puerto Rico is the U.S. dollar (USD). Credit cards are widely accepted.

Hurricane season

Hurricanes usually occur from mid-May to the end of November. During this period, even small tropical storms can quickly develop into major hurricanes.

These severe storms can put you at risk and hamper the provision of essential services.

If you decide to travel to a coastal area during the hurricane season:

• know that you expose yourself to serious safety risks
• be prepared to change your travel plans on short notice, including cutting short or cancelling your trip
• stay informed of the latest regional weather forecasts
• carry emergency contact information for your airline or tour operator
• follow the advice and instructions of local authorities
• Tornadoes, cyclones, hurricanes, typhoons and monsoons
• Large-scale emergencies abroad
• Active storm tracking and hurricane watches and warnings  - United States’ National Hurricane Center

Puerto Rico Emergency Management Bureau  - United States Homeland Security

Local services

Dial 911 for emergency assistance.

Consular assistance

Florida, Puerto Rico, US Virgin Islands

For emergency consular assistance, call the Consulate General of Canada to the United States, in Miami, and follow the instructions. At any time, you may also contact the Emergency Watch and Response Centre in Ottawa.

The decision to travel is your choice and you are responsible for your personal safety abroad. We take the safety and security of Canadians abroad very seriously and provide credible and timely information in our Travel Advice to enable you to make well-informed decisions regarding your travel abroad.

The content on this page is provided for information only. While we make every effort to give you correct information, it is provided on an "as is" basis without warranty of any kind, expressed or implied. The Government of Canada does not assume responsibility and will not be liable for any damages in connection to the information provided.

If you need consular assistance while abroad, we will make every effort to help you. However, there may be constraints that will limit the ability of the Government of Canada to provide services.

Learn more about consular services .

Risk Levels

  take normal security precautions.

Take similar precautions to those you would take in Canada.

  Exercise a high degree of caution

There are certain safety and security concerns or the situation could change quickly. Be very cautious at all times, monitor local media and follow the instructions of local authorities.

IMPORTANT: The two levels below are official Government of Canada Travel Advisories and are issued when the safety and security of Canadians travelling or living in the country or region may be at risk.

  Avoid non-essential travel

Your safety and security could be at risk. You should think about your need to travel to this country, territory or region based on family or business requirements, knowledge of or familiarity with the region, and other factors. If you are already there, think about whether you really need to be there. If you do not need to be there, you should think about leaving.

  Avoid all travel

You should not travel to this country, territory or region. Your personal safety and security are at great risk. If you are already there, you should think about leaving if it is safe to do so.

How To Be A Considerate Tourist When Visiting Puerto Rico

P uerto Rico is a much-loved destination for American travelers. Beyond the fact that U.S. citizens don't need a passport to travel there, the island is a great way to get the feel of a tropical getaway without having to go very far or exchange money . However, in the last few years (or the last few decades, if we're being honest), Puerto Rico has not been given the respect it deserves nor the care it so desperately needs.

You may remember in 2017 and 2022 when the territory was hit by Hurricanes Maria, Irma, and then Fiona. These natural catastrophes caused unprecedented damage to Puerto Rico's infrastructure, including their power grid which took 11 months to restore. The island's government estimated it would require nearly $132 billion to repair the damages, of which they have received only a fraction.

And if that wasn't bad enough, in the middle of these events, COVID-19 happened and Puerto Rico was swarmed by tourists looking for an escape from pandemic restrictions they faced back home. Even though Puerto Rico required masks, some visitors took a rules-for-thee-not-for-me approach. Now as the pandemic subsides and the island continues to rebuild, a question arises. How can we, as tourists, do better?

How To Travel Responsibly In Puerto Rico

Leave it better than you found it. Just a step above "leave no trace," this rule of conservation is globally espoused to encourage individuals to be more conscious of their impact on nature. Don't scour the trees with your and your lover's initials. Don't throw trash into the streets. Don't take pieces of rock or shells home from a beach that explicitly forbids it.

However, "leave it better than you found it" goes beyond the effects we have on our environment at home. It also applies to the places we travel. This is treating locals in Puerto Rico with respect, following the local laws and regulations, supporting locally owned establishments, and being an informed traveler. These are all things you can do to leave behind you a better impression of tourists from your country than those before you.

If you're traveling to Puerto Rico, consider lending a hand directly to a good cause. There are numerous volunteer opportunities throughout Puerto Rico where you can help local communities in a variety of ways.

You should also make sure the money you're spending is staying in the local economy. You can do this by buying food from local fishers, farmers, and restaurant owners and purchasing gifts made and distributed by local artisans. Lastly, when booking your accommodations, take the extra step to ensure it is independently owned. There are a variety of eco-conscious accommodations like this in Puerto Rico, so take your pick!

Support Puerto Rico By Being Informed

There are many ways to be a responsible traveler in Puerto Rico that go beyond just spending your money wisely. Learning a bit about the history of the island and current hardships communities are facing can make us all a bit more empathetic to the destinations we visit and the people who live there.

Puerto Rico , much like the mainland U.S., is a melting pot of cultures and ethnicities that include the Indigenous Taínos, Spanish, and African communities. This has led to an intermingling of cultural traditions that you can see and experience in every corner of the island. Don't make the mistake of missing out on local Indigenous food traditions or try your hand (or rather feet) at some Afro-Caribbean dance classes.

With such beautiful traditions also comes a respect for the local nature and wildlife. Puerto Rico is full of green tropical rainforests, stunning sandy beaches, sapphire blue waters, and the colorful fauna to match. Locals rely heavily on local ecosystems to support their own livelihoods as well as keep tourists coming back year after year.

It's estimated that the coral reefs alone generate $1.4 billion in revenue from tourism. So, be sure to book a snorkel or dive tour of the reefs with a responsible tour operator and wear your reef-safe sunscreen. You may also want to consider donating to the Nature Conservancy which works with local fishermen to promote more sustainable fishing methods and preserve food traditions.

Read this next: Best Beach Towns You've Never Heard Of

• Open access
• Published: 25 April 2024

“It didn’t hurt me”: patients’ and providers’ perspectives on unsupervised take-home doses, drug diversion, and overdose risks in the provision of medication for opioid use disorder during COVID-19 in San Juan, Puerto Rico

• Roberto Abadie 1 &
• Celia B. Fisher 2  

Harm Reduction Journal volume  21 , Article number:  85 ( 2024 ) Cite this article

72 Accesses

Metrics details

During the COVID−19 pandemic, clinics offering medication for opioid use disorder (MOUD) needed to rapidly introduce unsupervised take−home dosing, while relapsing patients and patients unable to enter treatment faced increased risks of fentanyl−related overdose deaths and other drug−related harms. Based on a qualitative study of people who inject drugs (PWID) receiving MOUD treatment and MOUD staff in Puerto Rico, this paper documents the lived experiences of patients and providers during this period and the risk perceptions and management strategies to address substance misuse and drug diversion attributable to unsupervised take−home−dose delivery.

In−depth qualitative interviews were conducted with patients (N = 25) and staff (N = 25) in two clinics providing MOUD in San Juan, Puerto Rico, during 2022. Patients and staff were receiving or providing treatment during the pandemic, and patients reported injection drug use during the past thirty days.

Patients were overwhelmingly male (84%), unmarried (72%), and unemployed (52%), with almost half (44%) injecting one to three times a day. Mean time in treatment was 7 years. Staff had a mean age of 46 years with more than half of the sample (63%) female. The majority of patients believed that unsupervised take−home dosing had no significant effect on their treatment adherence or engagement. In contrast, providers expressed concerns over the potential for drug diversion and possible increased risks of patient attrition, overdose episodes, and poor treatment outcomes.

This study underscores the importance of insider perspectives on harm−reduction changes in policy implemented during a health crisis. Of note is the finding that staff disagreed among themselves regarding the potential harms of diversion and changes in drug testing protocols. These different perspectives are important to address so that future pandemic policies are successfully designed and implemented. Our study also illuminates disagreement in risk assessments between patients and providers. This suggests that preparation for emergency treatment plans requires enhanced communication with patients to match treatments to the context of lived experience.

Introduction

COVID-19 saw an increase in mental health issues and substance abuse among the general population [ 1 , 2 ]. The effects of COVID-19 were particularly severe among people with OUDs. Limitations in health services during COVID-19 represented a serious challenge to people with OUDs because members of this population can be prone to conditions such as diabetes, cardiovascular problems, respiratory issues, or compromised immune systems. These vulnerabilities expose them to disproportionately high mortality risks [ 3 ]. Compounding these health risks, COVID-19 lockdown measures such as stay-at-home orders for nonessential workers and social distancing measures severely disrupted access to medication for OUD (MOUD) [ 4 ]. MOUD has shown positive effects, including reducing participation in illegal activities, drug use frequency, HIV risk behaviors, HCV transmission, and overdose episodes [ 5 , 6 , 7 , 8 , 9 ].

Thus, COVID−19 related stressors such as lack of income, isolation, and anxiety were compounded by changes in the drug supply, difficulties accessing harm−reduction resources, and stigma surrounding MOUD operations [ 10 , 11 ]. Patients receiving MOUD treatment, particularly in the lockdown phase, during which most restrictions were implemented, faced increased risks of relapse, treatment discontinuation, overdose episodes, and deaths and other drug−related harms [ 12 ].

While the impact of COVID-19 on people with OUDs has been significant, people who inject drugs (PWID) and, in particular, Puerto Rican PWID bore a disproportionate percentage of overdose deaths [ 13 , 14 , 15 ]. Although epidemiological data is not yet available, it is likely that increased drug use frequency led not only to an increase in overdose episodes and deaths but also higher HIV and HCV (Hepatitis C virus) risks among this vulnerable population. PWID on the island of Puerto Rico faced the effects of COVID-19 superimposed on an already existing epidemic of HCV [ 16 ]. According to the last US Census, almost half of the Puerto Rican population (44%) live in poverty, three times the rate of the continental US [ 17 ]. Among PWID, poverty levels are even higher, with almost half having been homeless at some point during the past year [ 18 ]; homelessness disproportionately exposes them to COVID-19 risks.

Faced with the unprecedented pandemic situation, MOUD clinics in Puerto Rico, like their counterparts in the continental US, were forced to improvise and adapt in order to ensure continuous treatment services to a vulnerable and highly at−risk population [ 19 , 20 , 21 , 22 ]. Unsupervised take−home dosing for patients, along with a significant reduction or even a temporary elimination of drug testing, was introduced, and new enrollments were completely eliminated or reduced to a trickle. As a result of these changes and disruptions, patients who experienced relapses or those unable to enter treatment faced increased risks of fentanyl−related overdose deaths and other drug−related harms. Studies conducted on the US main land have provided mixed results on the success of take−home dose procedures during COVID−19. For example, staff at a California site were able to introduce take−home doses cautiously, making individualized risk/benefit assessments based on the probability that a patient would engage in misuse leading to overdose risks with current patients reporting increased autonomy and flexibility, leading to increased program engagement and patients that were not eligible demanding more transparency in the way decisions were made [ 23 ]. Another qualitative study, conducted in New Jersey, showed similar results, suggesting that some patients viewed positively the convenience, reduced travel expenses to the clinic, along with reduced stigma, but some resented the lack of other forms of support, such as food, clothing, or access to harm−reduction materials [ 24 ]. In other main land sites, there was evidence that for some patients unsupervised take−home dosing was never implemented or was implemented inconsistently [ 25 ] and that unhoused patients perceived take−home measures as impractical, unjust, and enhancing existing inequalities in treatment access [ 26 ]. In many MOUD sites in Puerto Rico, immediate restrictions on services posed by public health officials did not provide staff the opportunity to proceed cautiously or tailoring take−home doses to individual patient needs. In addition, harm reduction services on the Island were still suffering from the economic and health upheavals caused by Hurricane Maria when the pandemic hit. Thus, it is important to understand how patients and staff in Puerto Rico experienced unsupervised home delivery, disruptions at the clinics and the multiple services they were able to provide.

This paper aims to document the lived experiences of Puerto Rican MOUD patients and providers during the COVID−19 pandemic. Specifically, their risk perceptions and management strategies to address treatment needs, substance misuse and drug diversion attributable to unsupervised take−home−dose delivery during the pandemic.

The study was conducted among active PWID enrolled in MOUD treatment and staff at two clinics located in San Juan, Puerto Rico’s capital. San Juan and its metropolitan area concentrate almost two-thirds of the island’s 3.5 million people and contain the largest population of PWID and the majority of centralized MOUD resources. The capital was disproportionately affected by COVID-19, with close to 192,802 cases at the time of this submission [ 27 ].

PWID were and still are particularly vulnerable to overdose risks and other drug−related harms, and their views—as well as the perceptions of their providers—should be taken into account when designing harm−reduction strategies for a future pandemic.

Participants

PWID receiving MOUD and health care workers providing treatment were drawn from the same clinics in San Juan, Puerto Rico. One clinic was a relatively small, community-oriented, office-based buprenorphine site (Clinic A), and the other was a large Opioid Treatment Program (OTP) (Clinic B). Methadone provided at OTP clinics is classified by the federal government as a Schedule II controlled substance with high potential for abuse, while Buprenorphine is classified as a Schedule III controlled substance with lower potential for abuse compared with Schedule I and II, but still with potential for misuse. For this reason, the medications therapeutic use is strictly controlled by federal regulations, particularly in relation to take-home dosing requirements [ 28 ]. Before the pandemic, take-home doses were allocated based on a number of factors, such as the patients’ adherence to treatment, determined by regular urine tests and frequency of visits, as well as the need to comply with program rules and regulations. These regulations sought to balance the need to provide access to medication while minimizing the risk of drug diversion and misuse. During COVID-19, take-home dosing requirements were relaxed, moving all patients to an unsupervised take-home regimen that minimized and, in some cases, completely eliminated drug testing requirements [ 29 ].

To understand patient and staff views regarding changes in the provision of MOUD during COVID-19 and, in particular, the risks/benefits derived from the decision to increase take-home doses while significantly reducing or eliminating drug testing, this study recruited 25 active PWID users and 25 MOUD staff drawn from the same two clinics in San Juan. PWID were included if they were 19 years or older, had injected at least once in the past 30 days and were receiving treatment at a MOUD clinic during the COVID-19 pandemic. Staff were included if they had been providing services at one of the clinics when the pandemic emerged. The staff sample included a wide range of positions: Front staff in charge of receiving the patient, nurses administering the medication, drug counselors, social workers, and physicians overseeing the medical supervision of the treatment. During the pandemic, the staff had a wide range of years of experience, from months to decades (see Table  2 ).

A snowball sampling technique was utilized to recruit both samples. This recruitment method relies on participants assisting the researcher to identify and enroll other prospective study subjects [ 30 ]. A flyer with a description of the study was distributed in both clinics, and prospective participants were screened for eligibility via a phone-based questionnaire. Using a combined sample size (N = 50) produced data saturation. There were 6 patients and 14 staff recruited from Clinic A (office-based buprenorphine), and 19 patients and 11 staff from clinic B (OTP clinic).

Data collection

We administered a semi-structured questionnaire to collect data about the experiences of patients and clinic staff seeking/providing care during COVID-19. While the questionnaires probed study participants on the same topics, questions were modified to reflect their different experiences and positions. The first portion of the questionnaire employed closed-ended sociodemographic questions including gender, race/ethnicity, age, education, income, marital status, homelessness, substance and injection use history, and previous courses of and current duration of MOUD treatment. Data obtained from clinic staff also included total years spent in the MOUD treatment field and current position. The qualitative portion of the questionnaire followed the quantitative questions and relied on open-ended questions to collect data about participants’ perceptions of the risks and potential benefits associated with changes in MOUD home delivery during COVID-19 including the potential for medication diversion risk, fears of and perceived frequency of drug overdose episodes and deaths related to take-home procedures, and the effects on treatment attrition caused by the introduction of take-home doses and the reduction or elimination of drug testing controls essential for monitoring drug intake. Interviews were conducted in Spanish by a native speaker and translated into English for analysis. All participants signed an informed consent. Patients received $50 in cash as compensation for their time and efforts. Most of the staff members refused any compensation for their participation. The study received IRB approval from the University of Nebraska-Lincoln.

Analytic plan

Sociodemographic variables were analyzed to produce descriptive statistics of the population under study. All audiotaped interviews were transcribed and translated from Spanish to English. The transcripts were analyzed with the qualitative analysis software Dedoose. The authors and two research assistants, working simultaneously and collaboratively, undertook the coding. The team used a code book to standardize coding procedures and to solve coding disagreements. Following an inductive procedure, transcribed interviews were grouped into themes, either preestablished themes contained in our interview guide, or “a priori,” and “emergent” themes drawn inductively from the data [ 31 ]. The research team iteratively revised and regrouped these codes until they represented a set of higher-level axial codes describing participants’ MOUD treatment experiences as well. A posterior phase in data analysis used the codes produced in the first analytic phase to identify participants’ risk perceptions that better represented the risks related specifically to the changes introduced during COVID-19 in the provision of treatment, providing a textured account of the multiple ways that participants made sense of and navigated overdose risks and other drug-related harms during the pandemic.

Similarities and differences in patients’ and staff perspectives on the risks associated with unsupervised take-home dosing during COVID-19 and the strategies staff employed to manage overdose risks emerged from the qualitative analysis. We begin with a description of participant sociodemographics, followed by qualitative analysis of patient’s perspectives, followed by provider perspectives and ending with a discussion of similarities and differences in experiences and perspectives and recommendations for harm reduction policies for future pandemics.

Characteristics of participating patients and staff

Table 1 presents demographic data for patients. The sample had a mean age of 46 years. More than three quarters (84%) were male, and more than half (64%) had been homeless during the past year. Approximately three quarters (72%) were single, and a similar proportion (84%) had achieved a high school diploma or less. Participants were mostly unemployed (52%) with an annual income of $312. Almost half injected one to three times a day and had been in MOUD treatment for seven years.

Table 2 presents demographic data for staff. Staff had a mean age of 46 years with more than half of the sample (63%) female, 7% had been homeless during the past year and approximately half (55%) were married or in a living arrangement as married. Approximately half (55%) had completed post graduate studies and four in five approximately (81%) were employed and working full time with an estimated monthly income of $3,229. On average staff had worked in MOUD clinics for 13 years, 40% provided mental health services.

Qualitative themes

This study presents patients’ and staff perspectives on the benefits and risks associated with unsupervised take home dosing during Covid-19 and the strategies staff employed to manage overdose risk. Our qualitative analysis identified two overarching themes related todrug diversion and overdose risks and the value of drug- testing. The first section presents the patients’ perspectives, followed by the views of the staff.

Patients’ perception of the risks of drug diversion in response to take-home dosing during COVID-19

One concern during the pandemic was that the implementation of policies that approved take-home doses and the limitation in the capacity to conduct drug tests could increase the probability that patients would divert personal use to selling methadone and buprenorphine to others,. jeopardizing and increasing substance misuse.

The majority of patients interviewed do not indicate concerns about drug diversion. Patients talked about the importance of adhering to their own treatment in order to avoid the painful effects of heroin withdrawal: “… because I’m really on a pretty high dose, you know what I mean, and if I don’t take it, believe me I feel sick.” While none of the patients mentioned that they had sold their medication, many acknowledged they had “friends” who did and why people would be eager to buy it:

“I didn’t do it [sell the take-home dose], but there are many people who do, even when I stopped taking Methadone, I resorted to buying from people who sold it because they [the Methadone program] kind of cut me off, you know, and I started to feel the withdrawal effects too, and then I had to buy a couple of bottles to get off myself at home.”

“It didn’t hurt me”: patient perspectives on interrupted drug-testing during COVID-19

Pre-COVID MOUD policies required unscheduled drug testing to ensure that patients were compliant with prescribed medications and to detect whether other illicit substances were being used, which could compromise treatment outcomes. During this period, not only were COVID-19 lockdown and/or distancing measures a concern, but the island also was suffering from an increased number of overdose episodes and deaths caused by the presence of fentanyl in the drug supply.

Some patients did not seem particularly worried that less frequent or even a complete lack of drug testing might tempt them to use their drug of choice while still enrolled in MOUD: “I mean I’ve always tried to have my treatment, you know, that I don’t see myself without treatment, you know, that didn’t hurt me.” However, other patients pointed to an increased risk of overdose deaths due to unknown quantities of fentanyl in the drug supply: “Yes, because there have already been deaths due to fentanyl, that [lack of drug testing] does worry me.” In addition, some patients acknowledged that the lack of testing could be an incentive for substance use: “Because they don’t do the tests, that’s why you use substances. If you know they do, tomorrow they will take your urine, you won’t use because you know they will punish you or they will do something, so it wouldn’t be convenient for you.”

Other patients felt “let down” by the disruptions in drug testing, believing that this choice might have hurt them by removing a check on their drug use behavior:

I think it was a mistake. They should have found a way to continue testing, because there were many of us who fell down [i.e., relapsed], let me emphasize, because they were not taking urine or anything. I understand the thing about the disease, but they could have made an adjustment: “I give you the cup, you take it, from here to there, the bathroom is very big.” Many of us left, I am going to tell you, people who had 20 or 20-something bottles of stay at home fell down. (Clinic B).

Staff concerns about drug diversion due to unsupervised home dosing

Despite the clinics’ inability to conduct routine urine tests because of a lack of staff and other limitations imposed during the lockdown phase of COVID-19, their staffs were aware that diversion was occurring: “Speaking the truth, there is always someone who does it, that’s how it is, I’m not going to cover the sky with my hands because it happens.”

The perception of staff at both clinics was that most participants might have engaged in drug diversion even before COVID-19 during the period where drug testing and take-home doses were available.

Yes, we were very concerned. We know that there are some participants who may be doing it. We have tried to make different strategies to minimize the risk of that happening, but there are always tricks and things, so it is something that worries us. We were concerned and we are very worried that it could happen. We come up with new strategies when we have our suspicions that this could be happening. So it is a concern that we have now and that we had before as well. (Clinic A).

According to staff, the main motivation for engaging in drug diversion seemed to be financial gain. Lack of jobs or income during the pandemic may have played a role in drug diversion: “Even participants who did not sell their medication before started to sell it because they have nothing, they have no job [during the pandemic]. They can make money and they start to sell, and the count was not being administered at that time.” (Clinic B).

Some staff suggested that drug diversion from take-home doses can also be even a “business” opportunity for some patients:

That is not even all of them, not all, but the majority, I understand that a percentage of these participants see it as a business already, to take the prescription and make money on the street. It is a business for them. I have the prescription, and right now a Suboxone on the street is worth 10 and even 12 dollars, we are talking about 10 and 12 dollars for a participant who takes 40 [units] like that, there you have a month, so they play with the system, they play. Not all of them, because many are committed to the process, they come to change, but there are others who do not, who come to seek monetary benefits. (Clinic A).

Staff efforts to minimize diversion during COVID-19

To minimize the risk of diversion during COVID-19, when drug tests were eliminated or severely restricted for weeks or months, clinics resorted to continuing with certain controls, such as random phone calls or the verification of lot numbers to make sure they correspond to the medication given, which had already been in place before the pandemic and that did not require the use of drug testing:

If the patient sells it, we have control of that because we always call them to count the medicine. In this clinic we count the envelopes. If we have doubts that this patient is selling the medicine, we call them at random, and they have to bring us the empty envelopes of the medicine with the ones that are there, and we verify it by the lot number. That has always been done in this clinic, and it continued to be done during the pandemic. (Clinic A).

Yet despite the clinics’ efforts to monitor substance use patterns and to control drug diversion, staff recognized that the measures implemented might not be entirely adequate but that clinics were constrained by the limitations imposed by COVID-19: “There can always be fear that it can happen [drug diversion] because we were in a moment where we had to make decisions and we could not have contact with patients” (Clinic B).

Staff differed in the extent to which they were concerned about the increased health risk of medication diversion for their patients noting its negative effects on treatment outcomes:

Physically it was noticeable that they were relapsing, but it is very worrying because there we can see that we have to work not only on the delivery of a drug but also on the adherence to the drug. (Clinic A).

Other staff members expressed few concerns, arguing that unsupervised take-home doses made treatment available in the event of a relapse: “If they relapsed, they had the medication available. What they did with the medication is another thing, but it seems to me from the little that I was able to see, when COVID was over, most did not return having significantly relapsed” (Clinic B).

Some among the staff expressed the view that monitoring patients is not the main role of staff, who should instead focus on delivering therapeutic interventions:

We are not here to monitor them. That question is not asked with a diabetic. Are you worried that a diabetic is selling insulin in the street or that someone who is on Viagra because he needs to have sex with his partner is selling it in the street? Nobody asks you that, because if they sell it or don’t sell it, the therapeutic processes are managed, it doesn’t worry me. (Clinic B).

Staff members agreed with the idea that testing interruptions or a lack of testing might increase patients’ desire to use their drugs of choice: “As long as toxicology is not carried out in any treatment program, then a patient with problematic substance use knows that I will not be monitored and I can use substances, so it can be a risk” (Clinic B).

While most staff members felt that the lack of testing might have encouraged substance use among patients at their clinics, not all staff agreed, noting that for a majority of patients the lack of testing had no effect but that for a relative minority of patients, those sent to the program by the judicial system, the lack of testing might have encouraged them to use their drug of choice more often:

This program is not punitive, so if you test positive it’s not like you’re going to get divine justice, it’s not like that. But we have a group of participants who are under legal pressure; in this group, surely not doing the tests might have been a motivation. In other words, most patients were going to carry on normally, as they know that this program is not a punitive program, but that we make a plan with them. It would have made no difference if they had been tested, they would have used the same amount, the person who was going to use it was going to use it the same way. (Clinic A).

Some staff members suggested that testing disruptions were not the only factor influencing participants’ desire to rely on their drugs of choice. In this view, the new stressors brought by COVID-19 on an already vulnerable population might have played a role as well:

In addition to having a problem, they had the pressure of what was happening, and that was a triggering factor for any person. Imagine a mental health patient, a patient who has problematic substance use. There were those thoughts a million times, as one says. So it increased the fact that they could use or not, that there would be lapses, that there would be relapses, that there would be overdoses. (Clinic A).

To minimize the treatment disruptions caused by the alterations to the drug testing regimes during the pandemic, some staff members suggested personalized risk assessments and the use of follow-up phone calls to patients deemed at risk to monitor drug diversion and treatment compliance: Yes, the concern was genuine, but we tried to prevent it through phone calls. We have patients that we already know are patients who do not have good bottle management, a problematic patient, because we always try to give them a more aggressive follow-up by phone to ensure that the treatment continues” (Clinic B).

Despite staff efforts to manage the risks presented by the disruptions to drug testing, the negative effects on participants were hard to avoid:

We found that after we reinstated them [the drug tests] we saw that participants who had been adherent before there was a change due to the pandemic; when we started to do toxicology tests they had recurrences, they had lapses in consumption, so yes, there was an effect because there are some stressors that you do not work on the level of mental health or physical health, which leads to these recurrences and these lapses, and yes, the participants had these effects. (Clinic B).

While most staff recognized that the changes in drug testing implemented as a result of COVID-19 might have increased the risks of treatment attrition, overdose deaths, and other health-related harms for participants, some staff members expressed doubts about the validity of drug tests in the way they are currently conducted in the context of MOUD: “I believe that doping tests no longer work for medical plans because doping tests should be random and sporadic to measure at some point, but patients can also adapt, because if they come every fifteen days or every month to seek treatment, they can make adjustments to avoid testing positive in the doping test. I think doping tests are overrated” (Clinic A).

However, other staff were more likely to harbor a stricter approach to unsupervised take-home doses during COVID-19 and resented the fact that patients who neither earned nor proved that they were deserving of the take homes would still receive them:

To have the benefit of this treatment, the first thing you have to observe is the behavior. Patients are always told that the behavior is the most important thing. I always tell them, “Conduct is like humility. It opens doors for you because the better you modify your habits, that way it will open the doors for you, that is, you will progress, but if you remain in that negative, even if you have what you have, one day you will lose it because you don’t want to. If you are a person who follows the treatment, this is going to open the door for you. You start with a bottle, and when you come to see you have all of them complete 27, which is depending on how you behave. (Clinic B).

The COVID-19 pandemic in Puerto Rico led to an unprecedented shift from clinic drug distribution and drug testing to unsupervised home dosing and disruption in drug testing. Overall, patients were less concerned about drug diversion than staff. The majority of patients reported that the availability of take-home doses and the relaxation of drug testing had no significant effect on their treatment adherence or engagement. Although some may not have wanted to admit drug diversion efforts during the pandemic, many indicated they felt the medications were helping them and feared the consequences of limiting their own doses to diversion Some patients appreciated the convenience of take-home doses during the Island shut down, but resented the relaxation of drug tests, perceiving the tests were a controlling mechanism that supported their treatment adherence.

In contrast, staff expressed greater concern that drug diversion was occurring and that lack of drug testing was increasing the risk of drug overdose. Both clinics were pragmatic, recognizing their response was limited by the constraints imposed by COVID-19 and the need to follow newly issued regulations to provide services during the pandemic. Yet, scale, organizational culture and treatment ideology shaped not only drug diversion risk perception and management strategies but their overall attitude to unsupervised take-home dosing.

While this study on drug diversion risks is novel, there is empirical evidence suggesting that despite a general framework establishing guidelines for unsupervised take-home doses during COVID-19, important differences in the way clinics implemented this measure can be found. For example, a large survey conducted by Livingston et al. among MOUD clinics in the Veteran Hospital Services showed that while methadone and buprenorphine delivery was affected, some patients tended to receive better coverage than others [ 32 ]. Another survey conducted with patients receiving take-home deliveries at SAMHSA during the pandemic found wide variability, with some patients receiving their at-home doses while others were still required to dose on site, increasing the risk of COVID-19 transmission [ 33 ].

Although the variability described by Livingston and Brothers were found within one large institution, other studies found that important differences in take-home-dose permission, risk perception, and management also exist across clinics. Even within Puerto Rico, a recent study found differences in the ways three community-based clinics responded to the challenges of providing treatment, including unsupervised take-home doses and limited capacity for drug testing [ 34 ]. The deficit in drug testing capacity reflects a larger weakness in the available heath infrastructure to support MOUD in Puerto Rico. OTPs are provided by a federally licensed facility through SAMHSA and cover more than 5000 patients [ 35 ]. According to recent estimates, office-based buprenorphine reaches 10,000 patients and is dispensed through a combination of prescriptions filled at pharmacies and comprehensive clinics that provide drug counseling, mental health services, and other forms of support while also monitoring patients’ adherence. Most patients are covered through Medicare/Medicare, with only a minority relying on private insurance. Treatment is concentrated in the capital, San Juan, its metropolitan area, and other large cities, with a paucity of medically assisted treatments in rural locations.

While the regulatory framework to access MOUD should be made more flexible in order to expand treatment access during any future pandemic [ 36 , 37 ], there is the potential for well-intentioned measures like standardized unsupervised take-home doses to unintentionally erect new barriers to treatment, increasing overdose risks and other drug-related harms for an already vulnerable population. This is particularly relevant for Puerto Rican PWID, where many risks for overdose deaths, from economic crisis and despair, to a lack of MOUD [ 38 ] syringe exchange providers, to incarceration rates for what are often nonviolent drug-related crimes [ 39 ] are magnified. The arrival of fentanyl on the island found a population that had already been significantly affected by a string of natural and economic disasters, including financial collapse during the summer of 2017, when the island was forced to declare bankruptcy and was placed by the US Congress under the administration of a fiscal board charged with managing its economy, and the back-to-back devastation of hurricanes Irma and Maria in the fall of 2017 [ 40 ].

While standardization policies provide a framework to provide unsupervised take-home doses during COVID-19, more attention should be paid to the particular local contexts and institutional cultures in order to understand not only their responses to the risks of drug diversion in unsupervised take-home dosing but, more generally, to understand the challenges they faced during COVID-19. Future pandemic preparation for MOUD should take into consideration not only the social contexts in which staff and patients seek and provide care but also, and critically, their lived experiences, perspectives, and knowledge. Failing to consider the views of vulnerable PWID patients when contemplating policy changes constitutes a form of injustice, devaluing the group’s experiences and knowledge and contributing to its stigmatization [ 41 ]. Input from the affected population has shown to improve not only the quality of policy recommendations but also, crucially, policy adoption [ 42 , 43 ] Frontline staff members at MOUD clinics are often rendered invisible in public health policy, which is often created by administrators who are not themselves responsible for the day-to-day implementation of crisis-driven treatment modifications. COVID-19 has required significant changes in MOUD services due to lack of adequate resources, need for quarantining and social distancing, and other institutional decisions affecting the standard of care.

Limitations

This study is based on a relatively small convenience sample, making the results difficult to generalize to other locations beyond Puerto Rico. Another limitation is that responses might be affected by desirability bias, particularly among patients who were active users. These patients might have underestimated the extent to which drug diversion occurred in the context of unsupervised take-home dosing or underestimated its effects on treatment adherence and engagement. In turn, it is conceivable that staff responses were influenced by desirability bias, tending to overestimate the efficacy of the measures they adopted to manage diversion risks. Nevertheless, we believe that the present study offers novel data on how minority patients and staff at two MOUD clinics perceived the risks associated with unsupervised take-home doses and the strategies they enacted to manage these risks.

This study underscores the importance of insider perspectives on harm reduction changes in policy implemented during a health crisis. This study shows that while most patients were not concerned about the possibilities of drug diversion during COVID-19, staff at both clinics not only expressed concerns but also attempted to manage risks by profiling and monitoring patients even given the limitations they faced during the lockdown phase of the pandemic. Of note is the finding that staff disagreed among themselves regarding the potential harms of diversion and changes in drug testing, and these different perspectives are important to address so that future pandemic policies are successfully designed and implemented. Our study also illuminates disagreement in risk assessments between patients and providers. This suggests that treatment plans include enhanced communication about these risks within the context of patients lived experience.

Availability of data and materials

Beyond the excerpts of the transcripts relevant to the study that are available within the paper, full transcripts cannot be shared publicly.

Abbreviations

Hepatitis C virus

Human immunodeficiency virus

Medication for OUD

Opioid use disorder

People who inject drugs

Substance abuse and mental health

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Abadie, R., Fisher, C.B. “It didn’t hurt me”: patients’ and providers’ perspectives on unsupervised take-home doses, drug diversion, and overdose risks in the provision of medication for opioid use disorder during COVID-19 in San Juan, Puerto Rico. Harm Reduct J 21 , 85 (2024). https://doi.org/10.1186/s12954-024-01006-w

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Received : 16 November 2023

Accepted : 12 April 2024

Published : 25 April 2024

DOI : https://doi.org/10.1186/s12954-024-01006-w

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