Increases in overdoses during the COVID-19 pandemic

In the years before the COVID-19 pandemic, there was mounting evidence that many countries were facing an “opioid crisis”.¹ For instance, the United States saw a 137% increase in overall drug overdoses and a 200% increase in opioid overdoses between 2000 and 2014.² Just over 2 years ago, the COVID-19 pandemic began, and there were early concerns that the pandemic’s impact on contemporary society would dramatically increase opioid and nonopioid overdoses.³ Many worried that social distancing, quarantines, decreased in-person activities, and other changes would harm the mental health of individuals at risk of overdoses.³ Published quantitative studies examining trends in opioid and nonopioid overdoses allow us to determine to what extent these fears have been borne out.

Prehospital data has proved valuable in examining overdose increases. Friedman et al queried a national-level database of emergency medical services (EMS) runs in the United States and compared the incidence of overdose-associated cardiac arrests per 100,000 EMS activations across prepandemic and pandemic periods. They found a 42.1% increase in overdose-associated cardiac arrests in 2020, with the highest increases among specific racial/ethnic minority populations (e.g., Latinx and Black or African American individuals), individuals living in impoverished communities, and individuals in Pacific states.⁴ Looking at EMS data within Kentucky between January 14, 2020, and April 26, 2020, Slavova et al found significant increases in opioid overdoses. Specifically, they noted a 17% increase in EMS transports for opioid overdoses, a 71% increase in EMS activations with no transports for opioid overdoses, and a 50% increase in overdose calls with deaths at the scene.⁵ Glober et al looked at data within Marion County, Indiana (Indianapolis metropolitan area) and found that EMS activations for overdose increased 43% after a stay-at-home mandate. Furthermore, EMS activations where naloxone was administered increased by 61%, and there was a 47% increase in deaths from drug overdose.⁶

Several studies have examined data at the emergency department (ED) level. Holland et al used data from 3500 EDs across 48 states to show that, between March 15, 2020, and October 10, 2020, visits for suicide attempts, general overdoses, and overdoses involving opioids specifically increased when compared with the same time periods in 2019.⁷ Similarly, Soares et al looked at data from 25 EDs in six states between January 2018 and December 2020 to track rates of overdose-related visits. They found that visits for overdoses increased by 10.5% in 2020 when compared with 2018 and 2019, despite overall ED visits decreasing by 14%. Visits for opioid overdoses, specifically, increased by 28.5%.⁸ Rodda et al looked at patients visiting two large EDs in San Francisco and found that deaths per day attributable to overdoses increased substantially during the early stages of the COVID-19 pandemic.⁹ Shreffler et al reported increases in overdoses at the University of Louisville ED between March 6 and June 25, 2020, despite decreases in overall ED volume.¹⁰ Data from a large health system in Philadelphia revealed that the share of opioid overdoses within their total volume increased when a stay-at-home order was in place.¹¹

Several studies used public health data to track overdose mortality rates. For instance, Cartus et al used data from the Centers for Disease Control and Prevention and found that overdose mortality in 2020 exceeded forecasts by roughly 12%.¹² Data from the state of Rhode Island revealed that overdose deaths increased by 28.1% when comparing January 1, 2020, to August 31, 2020, with the same period in 2019.¹³ In San Francisco, Appa et al used data from the Office of the Chief Medical Examiner to show that the median number of weekly overdose deaths increased by 50% when comparing the 8.5 months before and after the city’s shelter-in-place order.¹⁴ In Ohio, Currie et al showed a sharp rise in fatal overdoses beginning after a national emergency was declared and peaking in the week of May 31, 2020.¹⁵ Finally, in Cook County, Illinois (Chicago), Mason et al found a dramatic increase in opioid overdose deaths during the time an 11-week stay-at-home order was put in place.¹⁶

The available literature indicates that overdoses have increased concurrently with the COVID-19 pandemic. However, differences across published reports indicate the precise magnitude of increases in overdoses varies, likely dependent on geographic, temporal, sociocultural, and demographic characteristics. Nguyen and Buxton discussed several public health developments that may explain increased overdoses, including social isolation, resource reallocation, closure of businesses/places of employment, and transportation restrictions.¹⁷ Although combating increases in overdoses attributable to the pandemic may present a unique challenge, it is clear that urgent public health efforts are needed to reduce the burden of overdoses. Furthermore, planning for future pandemics ought to consider potential increases in overdoses.

—Aditya C. Shekhar
Icahn School of Medicine at Mount Sinai, New York City, NY and Center for Bioethics, Harvard Medical School, Boston, MA
shekhar.aditya.c@gmail.com
http://orcid.org/0000-0002-2710-2854

—J. Wesley Boyd, MD
Center for Bioethics, Harvard Medical School, Boston, MA and Center for Medical Ethics and Health Policy, Baylor College of Medicine, Houston, TX