Trend of emergency department substance overdose during coronavirus pandemic: Comments on a previous publication

Dear editors

We'd like to congratulate and thank Chandran et al regarding their recently published study in the American Journal of Emergency Medicine: “Impact of COVID-19 pandemic on emergency department (ED) substance use screens and overdose presentations” [1]. The authors' data demonstrated an increased rate in visits for intoxication and positive substance abuse screening in the Washington, DC-Baltimore metropolitan area during the early phase of the COVID-19 pandemic. While we mostly agreed with the authors' evaluation of factors which might have contributed to this trend, we presented data that suggest access to extra funds, rather than financial hardships, may be one of the driving factors.

As part of the Coronavirus Aid, Relief and Economic Security Act (CARES Act), Americans were sent relief checks from the week of April 12, 2020 until the beginning of September 2020 [2]. We examined data from 435851 unique visits to 13 EDs and one urgent care within the Washington, DC – Baltimore area between January 01, 2019 and September 30, 2020 to determine the effect of this relief effort on ED overdose patterns. We identified 2950 adult patients who presented to the study EDs with chief complaints of any overdose during this period. We analyzed the trend of ED overdose by using an interrupted time series (ITS) analysis with the intervention period defined as the week of April 12-19, 2020. There was a downward trend of ED presentations for overdose during the pre-intervention period (January 01, 2019 – April 11, 2020) (Fig. 1 , line 1). This downward trend was predicted to continue after April 16, 2020 (Fig. 1, line 4). In contrast, there was a significant increase of overdose presentations following the intervention week, compared to the pre-intervention level (Fig. 1, point 2, intercept = 8.9, P = 0.048). We also observed a positive upward trend of overdose presentations in the week following the intervention week. The trend remained upward until the end of our study period, and although it was not statistically significant (Fig. 1, Line 3, coefficient = 0.48, P = 0.1), it was clinically important, because it was a drastic deviation from the downward trend predicted by the prior 15 months of historical data.

Fig. 1.

Interrupted time series analysis assessing the trend of patients who presented to the emergency departments with overdose. The weekly overdose number before (January 01, 2019 – April 11, 2020) and after (April 19, 2020 – September 30, 2020) relief checks were sent were compared.

We presented data suggesting that the increased trend of ED overdose may be associated with the relief checks being sent to Americans. Financial hardship would be unlikely to affect substance use disorder because substances are an “inelastic demand”. Therefore, price increases or lack of funds would not significantly alter demand [3]. For example, cocaine's and heroin's demands are rated at −0.5 and −0.3, respectively. In other words, these indices indicate that if the price increases by 1%, the demand for cocaine and heroin only reduces by 0.5% and 0.3%, respectively [4]. Thus, during this ongoing pandemic, when many factors are affecting patients' well-being and resilience, an extra income may have allowed the financial flexibility for some to resort to recreational drugs. Emergency departments can consider these socioeconomic factors while preparing for future public health crises.

Declaration of Competing Interest

This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.