Unprecedented increase in overdose deaths during the COVID-19 pandemic – with substantial regional variation

After experiencing a slight decrease in 2018, drug overdose deaths increased again in 2019, setting an all-time high. Preliminary reports from states and cities indicate that overdose death rates are further increasing during the COVID-19 pandemic. National data, too, support this increase in overdose deaths, though this evidence is not yet official. In this study, researchers further clarified the impact of COVID-19 on the opioid crisis by calculating month by month overdose counts during the pandemic.

WHAT PROBLEM DOES THIS STUDY ADDRESS?

The COVID-19 pandemic has exacerbated the opioid overdose crisis. As researchers seek to document and explain this impact, theoretical reasons given for increased public health harms include a more dangerous drug supply, disruption of treatment and recovery support services, social isolation, and increased levels of social and economic stress. Indeed, states and cities have documented increases in both nonfatal drug overdoses and overdose deaths. For example, Ohio and Rhode Island saw an increase in overdose deaths at the beginning of the pandemic, and the state of Kentucky and the cities of Richmond, VA and Indianapolis, IN saw an increase in nonfatal overdoses. A similar picture has emerged at the national level. Overdose-related cardiac events (a proxy for nonfatal overdoses) reported by emergency medical services increased in the initial months of the pandemic with peak rates in May 2020 more than 50% higher than May 2019. Provisional counts of drug overdose deaths, reported in 12-month rolling averages (see paragraph below for more details), also showed an increase during the pandemic. This is especially concerning given that overdose deaths had increased to an all-time high in 2019 before the pandemic arrived in the United States.

The Centers for Disease Control and Prevention (CDC) released an emergency advisory in December 2020 stating that, from June 2019 to May 2020, more than 81,000 people died of a drug overdose in the United States, 18% higher than the previous 12 months. However, this data represents a “rolling average” and only comprises the first three months of the pandemic. In other words, the more than 81,000 deaths reported are for the entire one-year period and are not broken down by month, thereby potentially masking a large spike during the pandemic. This is commonly done to stabilize rates and to understand trends over time but can also obscure sharp changes at a given time point needed to inform timely policy shifts. In this study, Friedman and Akre estimate monthly mortality values underlying the 12-month rolling average of provisional overdose death counts and break these values down by state. Findings from this study can quantify the impact of the COVID-19 pandemic on drug overdose deaths and identify which areas have been most impacted and provide vital resources.

HOW WAS THIS STUDY CONDUCTED?

This study used provisional drug overdose death data from the CDC to breakdown the 12-month rolling average into estimated monthly values nationally, by census region, and by state through the development of a model that uses a set of chained calculations and is calibrated with historical data that has been finalized.

This model was built upon a straightforward algorithm that was able to leverage two important facts: that drug overdose deaths have been finalized for 2019 and are available through CDC WONDER; and that the 12-month rolling averages were released monthly during the first five months of the pandemic.

The researchers used data at the state level and then aggregated this data to the level of census divisions and the national total. This afforded state-level, regional, and national data for the first five months of the pandemic.

WHAT DID THIS STUDY FIND?

Drug overdose deaths increased during the first five months of the pandemic.

Drug overdose counts increased by 23% and 36% for March 2020 and April 2020 respectively compared to corresponding monthly values in 2019. May 2020 was the deadliest month during the pandemic, with an estimated 9,192 people dying from a drug overdose, a 58% increase from May 2019. Mortality remained elevated in June 2020 and July 2020 with a 36% and 44% increase respectively compared to corresponding monthly values in 2019.

Figure 1.

The increase in drug overdose deaths was especially prominent in certain regions and states.

The East-South-Central (e.g., Alabama, Kentucky) census division had the highest increase in drug overdose deaths in May 2020 compared to May 2019 (99%), followed by the South Atlantic (e.g., Florida, North Carolina) census division (73%) and the Pacific (e.g., California, Washington) census division (62%). The New England (e.g., Massachusetts, Vermont) census division had the smallest drug overdose increase in May 2020 compared with May 2019 (25%). West Virginia, Kentucky, and Tennessee had the largest increases among states, with a 178%, 140%, and 98% increase in May 2020 respectively compared with May 2019.

Some states had a large spike in overdose deaths during the pandemic that was masked by the 12-month average.

In some instances, the states with the largest increases in drug overdose deaths were not the same states with the largest 12-month increases. For example, West Virginia had a 12-month rolling average increase of 22%, similar to Connecticut’s at 24%. However, West Virginia had a 178% increase in May 2020 compared with May 2019 whereas Connecticut had a 14% increase. Nevada had a decreasing 12-month average compared with the previous year but had a 63% increase in drug overdose deaths in May 2020 compared with May 2019.

WHAT ARE THE IMPLICATIONS OF THE STUDY FINDINGS?

Using a 12-month rolling average masked the large spike in overdose deaths during the first five months of the pandemic. This was especially evident among certain states, such as Nevada, which had a decreasing 12-month average compared with the previous year but had a 63% increase in drug overdose deaths in May 2020 compared with May 2019. This highlights the need to present monthly values alongside rolling averages to detect spikes in overdose deaths that get washed out by looking only at 12-month averages. In addition to more fine-grained, month to month, data, also, in general, having more rapid access to data for decision-makers is paramount to moving quickly to form an effective response. Thus, it is important to invest in better data infrastructure to build a robust surveillance system that can detect areas of acute need much more quickly.

Although there are many challenges to rapid reporting of drug overdose deaths, we have learned from the COVID-19 pandemic that pressing public health challenges can be met with near real-time surveillance systems. Therefore, there is likely significant room for improvement in our vital records systems regarding drug overdose deaths.

Figure 2.

Findings from this study indicate the possibility of approaching 100,000 drug overdose deaths in 2020, compared with just over 70,000 deaths in 2019, representing the largest year-to-year increase in recent history for United States and by far the largest absolute number of drug overdose deaths ever reported.

A comprehensive response is needed to address the opioid crisis. Although medications, such as methadone and buprenorphine, have been recognized as most effective in treating opioid use disorder, it is estimated that only 20% of individuals with this disorder receive specialty treatment and, among these, only a third receive these evidence-based medications. Innovative interventions are vital to address this treatment gap, such as initiating these medications at vital touchpoints including emergency departments and the criminal justice system. Other promising models for initiation include post-overdose response teams and peer outreach.

Sustaining the eased telehealth regulations around buprenorphine and the take-home regulations for those on methadone at Opioid Treatment Programs may also increase access to and retention in treatment. Online digital recovery support services have emerged as a complement to in-person mutual help organizations for people in recovery. Harm reduction strategies, such as distributing naloxone to those most likely to witness an opioid overdose, may be one of the most effective interventions for overdose prevention. Also, providing fentanyl testing strips that allow for rapid assessment of purchased drug supply by persons addicted to opioids to detect the presence of fentanyl – responsible for much of the increase in overdoses – can increase awareness of potential risk for overdose. Interventions that have been implemented in other countries that may be controversial in the United States may also be considered, such as expanding the role of healthcare facilities to distribute medications for opioid use disorder, opening overdose prevention sites in high-risk areas, and making available injectable opioid agonist therapy (i.e., “heroin-assisted therapy”) to those who are refractory to other treatment options.

Although most drug overdose deaths involve opioids, there has been a recent increase in these deaths involving cocaine and psychostimulants, such as methamphetamine. Some of the interventions listed above are specific to opioid use disorder. Critically, there are no FDA-approved medications for cocaine or methamphetamine disorder, but certain combinations of medications show promise. Particularly given that 80% of opioid-involved overdose deaths also involve another substance, interventions addressing the opioid crisis are likely to have a greater impact when tailored to individuals with polysubstance use.

Although demographic data was not available for the provisional data used in this study, other data suggest that individuals of Black race have been disproportionately affected by the increase in drug overdose deaths during the pandemic. This is especially concerning given that this population has also been disproportionately impacted by the pandemic itself. Any intervention implemented to address the opioid crisis should incorporate a plan for equitable access and impact across different racial groups. In addition, considering policies and interventions that improve social determinants of health among Black individuals may also have the indirect effect of reducing overall overdose deaths.

LIMITATIONS

This study was done using provisional drug overdose death data. Effect sizes from finalized data may be different, though the overall broader conclusion that drug overdose deaths increased substantially during the pandemic is likely to remain the same.
The model used by the authors assumed that historical lags in data reporting (i.e., the time from the overdose event to formal documentation) would be consistent over time. The pandemic may have prolonged these reporting lags, meaning that the findings may be conservative underestimates of overdose deaths during the pandemic.
Due to this being an observational study, we cannot infer from these data alone that the pandemic directly caused the increase in drug overdose deaths.

BOTTOM LINE

In this study, the research team found that unprecedented increases in drug overdose deaths occurred during the early months of the pandemic with May 2020 being the deadliest month. These deaths varied by state suggesting that some areas were disproportionately impacted. Using a 12-month rolling average masked the large spike in overdose deaths during the first five months of the pandemic.

For individuals and families seeking recovery: Potential reasons for the increase in drug overdose deaths during the pandemic include a more dangerous drug supply, disruption of treatment and recovery support services, social isolation, and increased levels of social and economic stress. Online digital recovery support services have emerged for people in recovery as an alternative to in-person mutual help organizations that have been disrupted by the pandemic. Given the uncertain and dangerous nature of the drug supply, people using drugs should never use alone and should always carry naloxone. People in recovery and their families should keep in contact with each other to combat social isolation.
For treatment professionals and treatment systems: Potential reasons for the increase in drug overdose deaths during the pandemic include a more dangerous drug supply, disruption of treatment and recovery support services, social isolation, and increased levels of social and economic stress. Online digital recovery support services have emerged for people in recovery as an alternative to in-person mutual help organizations that have been disrupted by the pandemic. Given the uncertain and dangerous nature of the drug supply, people using drugs should be strongly advised to never use alone and always carry naloxone. People in recovery and their families should be advised to keep in contact with each other to combat social isolation. Treatment professionals should become confident in delivering various treatment modalities via telehealth as this may increase access to treatment services with little impact on the quality of care.
For scientists: These findings highlight the shortcomings of reporting national data annually, especially if it is provisional data rolled into 12-month intervals. Wherever appropriate, monthly values should also be incorporated alongside these rolling averages to inform timely shifts in practice and policy. Though it is nearly certain that the pandemic is associated with an increase in drug overdose deaths, more research is needed to elucidate the exact nature of this relationship to understand why this has occurred, which could inform future policies and more targeted and precise interventions.
For policy makers: Findings from this study indicate the possibility of approaching 100,000 drug overdose deaths in 2020, representing the largest year-to-year increase in recent history for the United States and by far the largest absolute number of drug overdose deaths ever reported. A comprehensive response is needed to address the opioid crisis that considers innovative interventions. These may include treatment options based in harm reduction. Enhanced surveillance systems through investments in data infrastructure may be critical tools to inform such a comprehensive response. Though the pandemic is waning, there are many silver linings that could arise from this public health emergency, including treatment and recovery support service innovations that, if shown to improve outcomes, can be sustained over time. Policymakers should consider continuing to encourage treatment modalities delivered via telehealth given their added reach if empirical evidence shows that quality of care is not compromised, or individuals would not be able to seek services otherwise.