Abstract
During the COVID-19 pandemic, there was a marked increase in alcohol and drug-induced deaths. In the US, there was a rapid increase in the rate of alcohol- and drug-induced deaths within the first year of the COVID-19 pandemic compared to pre-pandemic years. This study examines mortality data within Hawai‘i to assess both alcohol and drug-induced mortality during the pandemic compared to the nation overall. Data from the Centers for Disease Control and Prevention Underlying Cause of Death database were used to compare numbers and rates of alcohol-induced, drug-induced, and all-cause deaths among individuals aged 15 years or older between 2018 and 2021. The percentage of alcohol-induced and drug-induced deaths in the US and Hawai‘i increased annually in 2018, 2019, 2020, and 2021. Unlike the US, in Hawai‘i between 2020 and 2021 the age-adjusted rate of drug-induced deaths per 100 000 people decreased from 20.6 to 18.6. Overall, this study found that alcohol-related deaths in Hawai‘i increased similarly to those in the US during the COVID-19 pandemic.
Keywords: alcohol-related death, drug-related death, COVID-19
Introduction
Worldwide, preliminary data around the impact of Coronavirus Disease of 2019 (COVID-19) have shown an acceleration in alcohol and drug-induced deaths.1 In the US, alcohol-induced deaths in the first year of the COVID-19 pandemic increased rapidly compared to pre-pandemic years.2 This increase was comparatively greater than the rate increase in all-cause mortality in 2019–2021.2 Similarly, drug-induced deaths increased during the COVID-19 pandemic, with over 95 000 persons in the US dying from drug-induced overdose in 2020.3 A 2020 study by the Addiction Policy Forum found that 20% of study participants with substance use disorder reported an increase in substance abuse during the COVID-19 pandemic.4 There is limited data on the COVID-19 pandemic condition’s effect on rising drug use, illicit drug supply changes, and treatment access.5 In 2004, the Alcohol and Drug Abuse Division of State of Hawai‘i Department of Health estimated that 85 468 people (9.7%) of the Hawai‘i population needed treatment for alcohol and/or other drug dependence and abuse, 81 377 (9.3%) needed treatment for alcohol dependence and abuse alone, and 15 186 (1.7%) needed treatment for drug dependence and abuse alone.6 This needs assessment also found that Hawai‘i’s drug choices favor substances that can be “easily grown or easily imported with minimal secondary processing” and that there is an aversion to intravenous drug use and an affinity for drugs that can be smoked.6 These factors and the geographically closed environment of an island state make the Hawaiian Islands a unique opportunity for comparison. This study examines mortality data within Hawai‘i to assess both alcohol and drug-related mortality during the pandemic compared to the nation overall.
Methods
Data from the Centers for Disease Control and Prevention (CDC) database for “Underlying Causes of Death, 1999–2021” was summarized and reviewed for alcohol-induced, drug-induced, and all-cause deaths between 2018 and 2021.3 All data queries included the following criteria: 15–100 years and older, year of death (between 2018 and 2021), and state where the death occurred. All state-level data with less than ten deaths in any category is suppressed by the CDC for patient privacy.3 Drug/alcohol-induced causes, as grouped by the CDC, were utilized to determine the cause of death.3 The drug/alcohol-induced causes grouping does not entirely correlate to International Classification of Diseases (ICD-10) codes but uses “‘recodes’ defined to support analysis by the selected causes of death groups.”3 Some ICD-10 codes included in this grouping include unintentional (ICD-10 X40-44), suicide (ICD-10 X60-64), homicide (ICD-10 X85), and undetermined drug and alcohol overdoses (Y10-14).3 Age-adjusted rates were calculated by the CDC using “weighted averages of the age-specific death rates, where the weights represent a fixed population by age.”3 Collected data were summarized and reviewed at the county and state of Hawai‘i level using Microsoft Excel, version 16.71 (Microsoft Corporation, Redmond, WA). State of Hawai‘i data was included within the total US data for analysis in this manuscript.
Results
Between 2018 and 2021, there were a total of 47 348 deaths from all causes in Hawai‘i and 12 422 217 deaths from all causes in the US (Table 1). There was a similar positive increase per year in the total number of alcohol-induced deaths and drug-induced deaths in the US and Hawai‘i between 2018 and 2021. Throughout this period, Hawai‘i had a higher percentage of drug-induced deaths per year than the total US except in 2021: 14.8% versus 13.4% in 2018, 16.8% versus 14.0% in 2019, 19.3% versus 18.0% in 2020, and 18.7% versus 20.7% in 2021, respectively. The age-adjusted rate of alcohol-induced deaths per 100 000 people increased in the US and Hawai‘i annually between 2018 and 2021: from 9.9 (95% CI 9.8–10.1) to 14.4 (95% CI 14.3–14.5) in the US and from 5.7 (95% CI 4.5–7.0) to 8.2 (95% CI 6.8–9.6) in Hawai‘i. (Table 2). The age-adjusted rate of drug-induced deaths per 100 000 people in the US increased 54% during this same period from 21.8 (95% CI 21.7–21.9) in 2018 to 33.6 (33.4–33.8) in 2021. The age-adjusted death rate for drug-induced deaths in Hawa‘i increased 30% from 2018 (15.8 [95% CI 13.7–17.9] in 2018) to 2021 (20.6 [95%CI 18.2–23.0]). Between 2020 and 2021, the age-adjusted rate of drug-induced deaths per 100 000 people in Hawai‘i was 20.6 (95% CI 18.2–23.0) and 18.6 (95% CI 16.4–20.9), respectively.
Table 1.
Total All-Cause, Alcohol-Induced, and Drug-Induced Deaths per Year in the US and Hawai‘i, 2018–20213
| 2018 | Percent of Total Deathsa (%) | 2019 | Percent of Total Deathsa (%) | 2020 | Percent of Total Deathsa (%) | 2021 | Percent of Total Deathsa (%) | |
|---|---|---|---|---|---|---|---|---|
| Total US | ||||||||
| All-Cause Deaths | 2808314 | -- | 2824597 | -- | 3354879 | -- | 3434427 | -- |
| Alcohol-Induced Deaths | 37329 | 7 | 39043 | 7.3 | 49061 | 9.2 | 54258 | 10.2 |
| Drug-Induced Deaths | 71147 | 13.4 | 74511 | 14 | 96096 | 18 | 111219 | 20.7 |
| Hawai‘i | ||||||||
| All-Cause Deaths | 11268 | -- | 11430 | -- | 11927 | -- | 12 723 | -- |
| Alcohol-Induced Deaths | 89 | 5.7 | 96 | 6.1 | 131 | 8.4 | 134 | 8.6 |
| Drug-Induced Deaths | 232 | 14.8 | 263 | 16.8 | 302 | 19.3 | 293 | 18.7 |
The percent of total deaths is calculated by dividing the total number of alcohol-induced or drug-induced deaths in a given year by the total all-cause deaths and multiplying by 100.
Table 2.
The Age-Adjusted Death Rate per 100 000 People per Year for Alcohol-Induced and Drug-Induced Causes of Death in the US and Hawai‘i, 2018–2021
| Age-Adjusted Death Rate (95% CI)a,b | ||||
|---|---|---|---|---|
| 2018 | 2019 | 2020 | 2021 | |
| Total US | ||||
| Alcohol-Induced Cause of Death | 9.9 (9.8–10.1) | 10.4 (10.3–10.5) | 13.1 (13.0–13.3) | 14.4 (14.3–14.5) |
| Drug-Induced Cause of Death | 21.8 (21.7–21.9) | 22.8 (22.6–22.9) | 29.5 (29.3–29.7) | 33.6 (33.4–33.8) |
| Hawai‘i | ||||
| Alcohol-Induced Cause of Death | 5.7 (4.5–7.0) | 5.9 (4.7–7.3) | 8.0 (6.6–9.5) | 8.2 (6.8–9.6) |
| Drug-Induced Cause of Death | 15.8 (13.7–17.9) | 17.5 (15.4–19.7) | 20.6 (18.2–23.0) | 18.6 (16.4–20.9) |
Rate per 100 000 population. All death rates are age-adjusted to the 2000 US Standard Population.
A 95% CI was calculated as the rate +/− 1.96 times the standard error. A standard error was calculated following the technical guidance of the National Vital Statistics Reports to take into account random variation.3
Discussion
Prior to the COVID-19 pandemic, 2018–2019, the percent increase in the percentage of alcohol-induced deaths in the US was similar to the percent increase in the percentage of alcohol-induced deaths in Hawai‘i, 4.3% and 4.5%, respectively. The percent increase in the percentage of alcohol-induced deaths continued to rise annually during the COVID-19 pandemic, with the US and Hawai‘i’s percentage of total alcohol-induced deaths in 2021 being 39.7% and 41% percent higher in 2021 than in 2019 before the COVID-19 pandemic. The percent increase in the age-adjusted rate of alcohol-induced deaths per 100 000 people in the US and Hawai‘i also increased during the COVID-19 pandemic by 38.5% and 39%, respectively. Previous research has suggested increasing alcohol consumption during the COVID-19 pandemic was a result of socioeconomic changes, disruption to mental health and substance use treatment services, and physical isolation.7 A2020 study by the Addiction Policy Forum found that 34% of participants with substance use disorder experienced disruptions in accessing treatment or recovery services, with 14% being unable to receive needed substance use disorder treatment services during the pandemic.4 The increased alcohol consumption and decreased access to substance use disorder treatment and recovery services were exacerbated by the first year of the COVID-19 pandemic lockdown likely contributed to the similar rate of increased alcohol-related deaths in the US and Hawai‘i.
The percentage increase in the percentage of drug-induced deaths also increased in the US and Hawai‘i before the COVID-19 pandemic, 2018–2019, 4.5% and 13.5%, respectively. At the national level, the percent increase in the percentage of drug-induced deaths increased substantially in 2020, the first year of the COVID-19 pandemic, by 28.6%, while Hawai‘i’s percent increase in the drug-induced percentage of total deaths only increased by 14.9%, similar to pre-pandemic levels. Hawai‘i actually had a 3.1% decrease in the total percent of drug-induced deaths in 2021, while the US saw a 15% increase in the total percent of drug-induced deaths during the same year of the COVID-19 pandemic. This negative trend is also reflected in the 9.7% decrease in the age-adjusted rate of drug-induced deaths in Hawai‘i per 100 000 people in 2021. The reduction in drug-related deaths between 2020 and 2021 could be attributed to reductions in supply and retail related to reduced drug trafficking and strict lockdown measures preventing social interaction for drug sales. Drug sales in Hawai‘i, in particular, may have been affected by the reduction in air transport.8 In 2021, the Hawai‘i High Intensity Drug Trafficking Area also found that the estimated cost of heroin was $120–$160 per gram, while methamphetamine was $40 per gram.9 After alcohol, methamphetamine remains Hawai‘i’s most prevalent drug of misuse among adults,10 as evidenced by an 87.5% increase in adults admitted to treatment for methamphetamine abuse in 2017.11 In 2021, the rate of drug overdose-related deaths nationally was highest for synthetic opiates (eg, fentanyl), followed by psychostimulants (eg, methamphetamine). A similar trend of increased methamphetamine use over heroin during the COVID-19 pandemic has also been found in Hawai‘i by practicing addiction medicine physicians.12 More research is needed to determine how the changing pattern of substance use nationally and in Hawai‘i is resulting in fewer deaths despite the increased use of psychostimulants like methamphetamine during the COVID-19 pandemic.13
Limitations
Due to privacy concerns at the state of Hawai‘i level, numerous alcohol-induced and drug-induced causes of death per year were suppressed by the CDC, limiting the ability to differentiate between the manner of alcohol and drug-induced death, such as unintentional versus suicide or homicide. Due to the above limitation, data analysis at the monthly level was also unable to be completed at the state of Hawai‘i level, which would have provided greater insight into data trends after the first US state-issued stay-at-home-order for the COVID-19 pandemic on March 19, 2020.2
Conclusion
These findings provide valuable insights into the impact of the COVID-19 pandemic on substance-related mortality rates in Hawai‘i. The decrease in drug-induced deaths in Hawai‘i during 2021, likely related to limited air travel during the COVID-19 lockdown, provides insight into the ability to help mitigate drug-induced deaths by more tightly monitoring airline passengers and cargo. Future investigations may provide insight into the long-term secondary health consequences of the COVID-19 pandemic, especially regarding alcohol and drug-related substance use. These findings may guide policy changes and targeted interventions to prevent and reduce these substance-related harms.
Glossary
Abbreviations
- CDC
Centers for Disease Control and Prevention
- COVID-19
Coronavirus Disease of 2019
- ICD-10
International Classification of Diseases version 10
Conflict of Interest
We certify that we have no financial affiliation/interest (eg, employment, stock holdings, consultantships, honoraria) in this manuscript’s subject matter, materials, or products. We have no conflict of interest to report nor any interests represented with any products discussed or implied.
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