Forecasted and Observed Drug Overdose Deaths in the US During the COVID-19 Pandemic in 2020

A simple heuristic for allocating opioid settlement funding to reduce overdose mortality in the United States

As resolution for opioid-related claims and litigation against pharmaceutical manufacturers and other stakeholders, state and local governments are newly eligible for millions of dollars of settlement funding to address the overdose crisis in the United States. To inform effective use of opioid settlement funds, we propose a simple framework that highlights the principal determinants of overdose mortality: the number of people at risk of overdose each year, the average annual number of overdoses per person at risk, and the average probability of death per overdose event. We assert that the annual number of overdose deaths is a function of these three determinants, all of which can be modified through public health intervention. Our proposed heuristic depicts how each of these drivers of drug-related mortality - and the corresponding interventions designed to address each term - operate both in isolation and in conjunction. We intend for this framework to be used by policymakers as a tool for identifying and evaluating public health interventions and funding priorities that will most effectively address the structural forces shaping the overdose crisis and reduce overdose deaths.

Excess Fatal Overdoses in the United States During the COVID-19 Pandemic by Geography and Substance Type: March 2020-August 2021

Objectives. To assess heterogeneity in pandemic-period excess fatal overdoses in the United States, by location (state, county) and substance type. Methods. We used seasonal autoregressive integrated moving average (SARIMA) models to estimate counterfactual death counts in the scenario that no pandemic had occurred. Such estimates were subtracted from actual death counts to assess the magnitude of pandemic-period excess mortality between March 2020 and August 2021. Results. Nationwide, we estimated 25 668 (95% prediction interval [PI] = 2811, 48 524) excess overdose deaths. Specifically, 17 of 47 states and 197 of 592 counties analyzed had statistically significant excess overdose-related mortality. West Virginia, Louisiana, Tennessee, Kentucky, and New Mexico had the highest rates (20-37 per 100 000). Nationally, there were 5.7 (95% PI = 1.0, 10.4), 3.1 (95% PI = 2.1, 4.2), and 1.4 (95% PI = 0.5, 2.4) excess deaths per 100 000 involving synthetic opioids, psychostimulants, and alcohol, respectively. Conclusions. The steep increase in overdose-related mortality affected primarily the southern and western United States. We identified synthetic opioids and psychostimulants as the main contributors. Public Health Implications. Characterizing overdose-related excess mortality across locations and substance types is critical for optimal allocation of public health resources. (Am J Public Health. 2024;114(6):599-609. https://doi.org/10.2105/AJPH.2024.307618).

Overdose deaths before and during the COVID-19 pandemic in a US county

Introduction

Globally, overdose deaths increased near the beginning of the COVID-19 pandemic, which created availability and access barriers to addiction and social services. Especially in times of a crisis like a pandemic, local exposures, service availability and access, and system responses have major influence on people who use drugs. For policy makers to be effective, an understanding at the local level is needed.

Methods

This retrospective epidemiologic study from 2019 through 2021 compares immediate and 20-months changes in overdose deaths from the pandemic start to 16 months before its arrival in Pinellas County, FL We examine toxicologic death records of 1,701 overdoses to identify relations with interdiction, and service delivery.

Results

There was an immediate 49% increase (95% CI 23-82%, p < 0.0001) in overdose deaths in the first month following the first COVID deaths. Immediate increases were found for deaths involving alcohol (171%), heroin (108%), fentanyl (78%), amphetamines (55%), and cocaine (45%). Overdose deaths remained 27% higher (CI 4-55%, p = 0.015) than before the pandemic through 2021.Abrupt service reductions occurred when the pandemic began: in-clinic methadone treatment dropped by two-thirds, counseling by 38%, opioid seizures by 29%, and drug arrests by 56%. Emergency transport for overdose and naloxone distributions increased at the pandemic onset (12%, 93%, respectively) and remained higher through 2021 (15%, 377%,). Regression results indicate that lower drug seizures predicted higher overdoses, and increased 911 transports predicted higher overdoses. The proportion of excess overdose deaths to excess non-COVID deaths after the pandemic relative to the year before was 0.28 in Pinellas County, larger than 75% of other US counties.

Conclusions

Service and interdiction interruptions likely contributed to overdose death increases during the pandemic. Relaxing restrictions on medical treatment for opioid addiction and public health interventions could have immediate and long-lasting effects when a major disruption, such as a pandemic, occurs. County level data dashboards comprised of overdose toxicology, and interdiction and service data, can help explain changes in overdose deaths. As a next step in predicting which policies and practices will best reduce local overdoses, we propose using simulation modeling with agent-based models to examine complex interacting systems.

PROVIDENT: Development and Validation of a Machine Learning Model to Predict Neighborhood-level Overdose Risk in Rhode Island

BACKGROUND

Drug overdose persists as a leading cause of death in the United States, but resources to address it remain limited. As a result, health authorities must consider where to allocate scarce resources within their jurisdictions. Machine learning offers a strategy to identify areas with increased future overdose risk to proactively allocate overdose prevention resources. This modeling study is embedded in a randomized trial to measure the effect of proactive resource allocation on statewide overdose rates in Rhode Island (RI).

METHODS

We used statewide data from RI from 2016 to 2020 to develop an ensemble machine learning model predicting neighborhood-level fatal overdose risk. Our ensemble model integrated gradient boosting machine and super learner base models in a moving window framework to make predictions in 6-month intervals. Our performance target, developed a priori with the RI Department of Health, was to identify the 20% of RI neighborhoods containing at least 40% of statewide overdose deaths, including at least one neighborhood per municipality. The model was validated after trial launch.

RESULTS

Our model selected priority neighborhoods capturing 40.2% of statewide overdose deaths during the test periods and 44.1% of statewide overdose deaths during validation periods. Our ensemble outperformed the base models during the test periods and performed comparably to the best-performing base model during the validation periods.

CONCLUSIONS

We demonstrated the capacity for machine learning models to predict neighborhood-level fatal overdose risk to a degree of accuracy suitable for practitioners. Jurisdictions may consider predictive modeling as a tool to guide allocation of scarce resources.

Cardiac Arrest Following Drug Overdose in the United States: An Analysis of the Cardiac Arrest Registry to Enhance Survival

BACKGROUND

Given increases in drug overdose-associated mortality, there is interest in better understanding of drug overdose out-of-hospital cardiac arrest (OHCA). A comparison between overdose-attributable OHCA and nonoverdose-attributable OHCA will inform public health measures.

METHODS AND RESULTS

We analyzed data from 2017 to 2021 in the Cardiac Arrest Registry to Enhance Survival (CARES), comparing overdose-attributable OHCA (OD-OHCA) with OHCA from other nontraumatic causes (non-OD-OHCA). Arrests involving patients <18 years, health care facility residents, patients with cancer diagnoses, and patients with select missing data were excluded. Our main outcome of interest was survival with good neurological outcome, defined as Cerebral Performance Category score 1 or 2. From a data set with 537 100 entries, 29 500 OD-OHCA cases and 338 073 non-OD-OHCA cases met inclusion criteria. OD-OHCA cases involved younger patients with fewer comorbidities, were less likely to be witnessed, and less likely to present with a shockable rhythm. Unadjusted survival to hospital discharge with Cerebral Performance Category score =1 or 2 was significantly higher in the OD-OHCA cohort (OD: 15.2% versus non-OD: 6.9%). Adjusted results showed comparable survival with Cerebral Performance Category score =1 or 2 when the first monitored arrest rhythm was shockable (OD: 28.9% versus non-OD: 23.5%, P=0.087) but significantly higher survival rates with Cerebral Performance Category score =1 or 2 for OD-OHCA when the first monitored arrest rhythm was nonshockable (OD: 9.6% versus non-OD: 3.1%, P<0.001).

CONCLUSIONS

Among patients presenting with nonshockable rhythms, OD-OHCA is associated with significantly better outcomes. Further research should explore cardiac arrest causes, and public health efforts should attempt to reduce the burden from drug overdoses.

Substance Use Treatment Utilization Among Individuals With Substance Use Disorders in the United States During the COVID-19 Pandemic: Findings on the Role of Polysubstance Use, Criminal Justice Involvement, and Mental Illness From the National Survey on Drug Use and Health

This study used the National Survey on Drug Use and Health to assess a nationally representative sample (N = 4596) weighted to represent 35.2 million adults with DSM-5 criteria-determined substance use disorders (SUDs). This study explored substance use treatment utilization in 2020, emphasizing populations with high vulnerability (e.g., criminal justice involvement (CJI) through parole or probation, polysubstance use, severe mental illness, and HIV/STI). Substance use treatment was broadly defined (any inpatient, outpatient/doctor's office, self-help/other for alcohol/drugs). Our results indicated that among adults with SUDs in 2020, 7 million (20%) had multiple SUDs, 1.75 million (5%) had CJI, 5.3 million (15%) had a severe mental illness, and 1.8 million (5%) had a diagnosis of HIV/STI in the last year. Only 7% of individuals with SUD sought any substance use treatment in the past year. CJI (aOR: 13.39, 95% CI: [7.82, 22.94]), serious mental illness (aOR: 3.27, 95% CI: [1.93, 5.55]), and having both 2 (aOR: 2.10, 95% CI: [1.29, 3.42]) or 3 or more SUDs (aOR: 3.46, 95% CI: [1.82, 6.58]) were all associated with a greater likelihood of receiving treatment. Marriage (aOR: 0.43, 95% CI: [0.25, 0.74]) and having an income twice the poverty threshold (aOR: 0.53, 95% CI: [0.29, 0.94]) were associated with reduced odds of receiving any substance use treatment. Compared to those 18 to 25, older individuals had increased odds (2-4 times) of receiving treatment. Interventions are crucially needed to increase access to treatment among those with SUDs.

Excess mortality in US Veterans during the COVID-19 pandemic: an individual-level cohort study

BACKGROUND

Most analyses of excess mortality during the COVID-19 pandemic have employed aggregate data. Individual-level data from the largest integrated healthcare system in the US may enhance understanding of excess mortality.

METHODS

We performed an observational cohort study following patients receiving care from the Department of Veterans Affairs (VA) between 1 March 2018 and 28 February 2022. We estimated excess mortality on an absolute scale (i.e. excess mortality rates, number of excess deaths) and a relative scale by measuring the hazard ratio (HR) for mortality comparing pandemic and pre-pandemic periods, overall and within demographic and clinical subgroups. Comorbidity burden and frailty were measured using the Charlson Comorbidity Index and Veterans Aging Cohort Study Index, respectively.

RESULTS

Of 5 905 747 patients, the median age was 65.8 years and 91% were men. Overall, the excess mortality rate was 10.0 deaths/1000 person-years (PY), with a total of 103 164 excess deaths and pandemic HR of 1.25 (95% CI 1.25-1.26). Excess mortality rates were highest among the most frail patients (52.0/1000 PY) and those with the highest comorbidity burden (16.3/1000 PY). However, the largest relative mortality increases were observed among the least frail (HR 1.31, 95% CI 1.30-1.32) and those with the lowest comorbidity burden (HR 1.44, 95% CI 1.43-1.46).

CONCLUSIONS

Individual-level data offered crucial clinical and operational insights into US excess mortality patterns during the COVID-19 pandemic. Notable differences emerged among clinical risk groups, emphasizing the need for reporting excess mortality in both absolute and relative terms to inform resource allocation in future outbreaks.

Risks of opioid overdose among New York State Medicaid recipients with chronic pain before and during the COVID-19 pandemic

OBJECTIVE

The COVID-19 pandemic contributed to healthcare disruptions for patients with chronic pain. Following initial disruptions, national policies were enacted to expand access to long-term opioid therapy (LTOT) for chronic pain and opioid use disorder (OUD) treatment services, which may have modified risk of opioid overdose. We examined associations between LTOT and/or OUD with fatal and non-fatal opioid overdoses, and whether the pandemic moderated overdose risk in these groups.

METHODS

We analyzed New York State Medicaid claims data (3/1/2019-12/31/20) of patients with chronic pain (N = 236,391). We used generalized estimating equations models to assess associations between LTOT and/or OUD (neither LTOT or OUD [ref], LTOT only, OUD only, and LTOT and OUD) and the pandemic (03/2020-12/2020) with opioid overdose.

RESULTS

The pandemic did not significantly (ns) affect opioid overdose among patients with LTOT and/or OUD. While patients with LTOT (vs. no LTOT) had a slight increase in opioid overdose during the pandemic (pre-pandemic: aOR:1.65, 95% CI:1.05, 2.57; pandemic: aOR:2.43, CI:1.75,3.37, ns), patients with OUD had a slightly attenuated odds of overdose during the pandemic (pre-pandemic: aOR:5.65, CI:4.73, 6.75; pandemic: aOR:5.16, CI:4.33, 6.14, ns). Patients with both LTOT and OUD also experienced a slightly reduced odds of opioid overdose during the pandemic (pre-pandemic: aOR:5.82, CI:3.58, 9.44; pandemic: aOR:3.70, CI:2.11, 6.50, ns).

CONCLUSIONS

Findings demonstrated no significant effect of the pandemic on opioid overdose among people with chronic pain and LTOT and/or OUD, suggesting pandemic policies expanding access to chronic pain and OUD treatment services may have mitigated the risk of opioid overdose.

The association between community social vulnerability and prescription opioid availability with individual opioid overdose

BACKGROUND

This study aims to assess the association of community social vulnerability and community prescription opioid availability with individual non-fatal or fatal opioid overdose.

METHODS

We identified patients 12 years of age or older from the Oregon All Payer Claims database (APCD) linked to other public health datasets. Community-level characteristics were captured in an exposure period (EP) (1/1/2018-12/31/2018) and included: census tract-level social vulnerability domains (socio-economic status, household composition, racial and ethnic minority status, and housing type and transportation), census tract-level prescriptions and community-level opioid use disorder (OUD) diagnoses per 100 capita binned into quartiles or quintiles. We employed Cox models to estimate the risk of fatal and non-fatal opioid overdoses events in the 12 months following the EP.

MAIN FINDINGS

We identified 1,548,252 individuals. Patients were mostly female (54%), White (61%), commercially insured (54%), and lived in metropolitan areas (81%). Of the total sample, 2485 (0.2%) experienced a non-fatal opioid overdose and 297 died of opioid overdose. There was higher hazard for non-fatal overdose in communities with greater OUD per 100 capita. We also found higher non-fatal and fatal hazards for opioid overdose among patients in communities with higher housing type and transportation-related vulnerability compared to the lowest quintile. Conversely, patients were at less risk of opioid overdose when living in communities with greater prevalence of the young or the elderly, the disabled, single parent families or low English proficiency.

CONCLUSION

These findings underscore the importance of the environmental context when considering public health policies to reduce opioid harms.

Translating Predictive Analytics for Public Health Practice: A Case Study of Overdose Prevention in Rhode Island

Prior applications of machine learning to population health have relied on conventional model assessment criteria, limiting the utility of models as decision support tools for public health practitioners. To facilitate practitioners' use of machine learning as a decision support tool for area-level intervention, we developed and applied 4 practice-based predictive model evaluation criteria (implementation capacity, preventive potential, health equity, and jurisdictional practicalities). We used a case study of overdose prevention in Rhode Island to illustrate how these criteria could inform public health practice and health equity promotion. We used Rhode Island overdose mortality records from January 2016-June 2020 (n = 1,408) and neighborhood-level US Census data. We employed 2 disparate machine learning models, Gaussian process and random forest, to illustrate the comparative utility of our criteria to guide interventions. Our models predicted 7.5%-36.4% of overdose deaths during the test period, illustrating the preventive potential of overdose interventions assuming 5%-20% statewide implementation capacities for neighborhood-level resource deployment. We describe the health equity implications of use of predictive modeling to guide interventions along the lines of urbanicity, racial/ethnic composition, and poverty. We then discuss considerations to complement predictive model evaluation criteria and inform the prevention and mitigation of spatially dynamic public health problems across the breadth of practice. This article is part of a Special Collection on Mental Health.

Trends in self-reported non-fatal overdose and patterns of substance use before and during the COVID-19 pandemic in a prospective cohort of adults who have injected drugs - Baltimore, Maryland, 2014-2022

BACKGROUND

Overdose deaths increased during the COVID-19 pandemic in the United States. Less is known about drug use behavior changes during the same time period. We examined differences in non-fatal overdose and drug use behaviors before and after the start of the COVID-19 pandemic in a community-recruited cohort of adults who have injected drugs.

METHODS

721 participants attended 7401 visits between Jan 2014 and Mar 2022. Outcomes (non-fatal overdose, drug route of administration, type of drugs used) were assessed via self-report in the last six months. We compared pre-pandemic (Jan 2014-Mar 2020) to inter-pandemic (Dec 2020-Mar 2022) prevalence of each outcome using Cohcrane-Maentel-Haeszel odds ratios (CMH-OR). We then estimated probabilities for transitioning between specific behaviors from participants' last pre-pandemic visit to their first inter-pandemic visit.

RESULTS

Comparing pre-pandemic visits to inter-pandemic visits, the prevalence of non-fatal overdose did not change (CMH-OR 1.06, 95% CI 0.75-1.50); the prevalence of injection (CMH-OR 0.13, 95% CI 0.1-0.17) and non-injection (CMH-OR 0.51, 95% CI 0.42-0.61) drug use declined. More than a third (35.7%) of persons using both injection and non-injection drugs pre-pandemic transitioned to exclusive non-injection use during the pandemic. By contrast, few (4.0%) persons using non-injection drugs exclusively pre-pandemic transitioned to injecting during the pandemic.

CONCLUSION

Among adults who have injected drugs, the start of the COVID-19 pandemic was associated with a reduced drug use prevalence and transitions from injection to non-injection use. Average overdose prevalence was unchanged, but these behavior changes may have helped mitigate overdose harm.

Excess US Firearm Mortality During the COVID-19 Pandemic Stratified by Intent and Urbanization

This cross-sectional study used time series forecasting to estimate excess firearm mortality in the US during the COVID-19 pandemic.

Racial differences in COVID-19 severity associated with history of substance use disorders and overdose: Findings from multi-site electronic health records in New York City

Substance use disorders (SUD) are associated with increased risk of worse COVID-19 outcomes. Likewise, racial/ethnic minority patients experience greater risk of severe COVID-19 disease compared to white patients. Providers should understand the role of race and ethnicity as an effect modifier on COVID-19 severity among individuals with SUD. This retrospective cohort study assessed patient race/ethnicity as an effect modifier of the risk of severe COVID-19 disease among patients with histories of SUD and overdose. We used merged electronic health record data from 116,471 adult patients with a COVID-19 encounter between March 2020 and February 2021 across five healthcare systems in New York City. Exposures were patient histories of SUD and overdose. Outcomes were risk of COVID-19 hospitalization and subsequent COVID-19-related ventilation, acute kidney failure, sepsis, and mortality. Risk factors included patient age, sex, and race/ethnicity, as well as medical comorbidities associated with COVID-19 severity. We tested for interaction between SUD and patient race/ethnicity on COVID-19 outcomes. Findings showed that Non-Hispanic Black, Hispanic/Latino, and Asian/Pacific Islander patients experienced a higher prevalence of all adverse COVID-19 outcomes compared to non-Hispanic white patients. Past-year alcohol (OR 1.24 [1.01-1.53]) and opioid use disorders (OR 1.91 [1.46-2.49]), as well as overdose history (OR 4.45 [3.62-5.46]), were predictive of COVID-19 mortality, as well as other adverse COVID-19 outcomes. Among patients with SUD, significant differences in outcome risk were detected between patients of different race/ethnicity groups. Findings indicate that providers should consider multiple dimensions of vulnerability to adequately manage COVID-19 disease among populations with SUDs.

Estimated Reductions in Opioid Overdose Deaths With Sustainment of Public Health Interventions in 4 US States

Importance

In 2021, more than 80 000 US residents died from an opioid overdose. Public health intervention initiatives, such as the Helping to End Addiction Long-term (HEALing) Communities Study (HCS), are being launched with the goal of reducing opioid-related overdose deaths (OODs).

Objective

To estimate the change in the projected number of OODs under different scenarios of the duration of sustainment of interventions, compared with the status quo.

Design, Setting, and Participants

This decision analytical model simulated the opioid epidemic in the 4 states participating in the HCS (ie, Kentucky, Massachusetts, New York, and Ohio) from 2020 to 2026. Participants were a simulated population transitioning from opioid misuse to opioid use disorder (OUD), overdose, treatment, and relapse. The model was calibrated using 2015 to 2020 data from the National Survey on Drug Use and Health, the US Centers for Disease Control and Prevention, and other sources for each state. The model accounts for reduced initiation of medications for OUD (MOUDs) and increased OODs during the COVID-19 pandemic.

Exposure

Increasing MOUD initiation by 2- or 5-fold, improving MOUD retention to the rates achieved in clinical trial settings, increasing naloxone distribution efforts, and furthering safe opioid prescribing. An initial 2-year duration of interventions was simulated, with potential sustainment for up to 3 additional years.

Main Outcomes and Measures

Projected reduction in number of OODs under different combinations and durations of sustainment of interventions.

Results

Compared with the status quo, the estimated annual reduction in OODs at the end of the second year of interventions was 13% to 17% in Kentucky, 17% to 27% in Massachusetts, 15% to 22% in New York, and 15% to 22% in Ohio. Sustaining all interventions for an additional 3 years was estimated to reduce the annual number of OODs at the end of the fifth year by 18% to 27% in Kentucky, 28% to 46% in Massachusetts, 22% to 34% in New York, and 25% to 41% in Ohio. The longer the interventions were sustained, the better the outcomes; however, these positive gains would be washed out if interventions were not sustained.

Conclusions and Relevance

In this decision analytical model study of the opioid epidemic in 4 US states, sustained implementation of interventions, including increased delivery of MOUDs and naloxone supply, was found to be needed to reduce OODs and prevent deaths from increasing again.

NYC RxStat: Stakeholder perspectives on a national model public health and public safety partnership to reduce overdose deaths

NYC RxStat, the United States' first public health and public safety partnership aiming to reduce overdose deaths, began in 2012 and established a national model for cross-sector partnerships. The partnership aimed to integrate data-driven policing with actionable public health interventions and surveillance to develop and implement cross-sector overdose responses. With federal support, jurisdictions nationally have implemented public health and public safety partnerships modeled on RxStat. To inform partnership replication efforts, we conducted a stakeholder evaluation of RxStat. We conducted in-depth, semi-structured interviews with 25 current and former RxStat stakeholders. Interviews probed stakeholder perceptions of RxStat's successes, challenges, and opportunities for growth. Interview data were iteratively coded and thematically analyzed. Stakeholders reported certainty about the need for cross-sector collaboration and described cross-disciplinary tensions, challenges to collaboration and implementation, and opportunities for partnership optimization and growth. Findings informed 12 strategies to improve RxStat and partnerships in its model, organized into three opportunity areas: (1) ensure stakeholder and agency accountability; (2) build secure and mutually beneficial data systems; and (3) structure partnerships to facilitate equitable collaboration. Cross-sector partnerships offer a promising strategy to integrate the public health and safety sectors, but disciplinary tensions in approach may hamper implementation. Findings can inform efforts to implement and scale cross-sector partnerships.

Overall and Telehealth Addiction Treatment Utilization by Age, Race, Ethnicity, and Socioeconomic Status in California After COVID-19 Policy Changes

Importance

Addiction treatment rapidly transitioned to a primarily telehealth modality (telephone and video) during the COVID-19 pandemic, raising concerns about disparities in utilization.

Objective

To examine whether there were differences in overall and telehealth addiction treatment utilization after telehealth policy changes during the COVID-19 pandemic by age, race, ethnicity, and socioeconomic status.

Design, Setting, and Participants

This cohort study examined electronic health record and claims data from Kaiser Permanente Northern California for adults (age ≥18 years) with drug use problems before the COVID-19 pandemic (from March 1, 2019, to December 31, 2019) and during the early phase of the COVID-19 pandemic (March 1, 2020, to December 31, 2020; hereafter referred to as COVID-19 onset). Analyses were conducted between March 2021 and March 2023.

Exposure

The expansion of telehealth services during COVID-19 onset.

Main Outcomes and Measures

Generalized estimating equation models were fit to compare addiction treatment utilization during COVID-19 onset with that before the COVID-19 pandemic. Utilization measures included the Healthcare Effectiveness Data and Information Set of treatment initiation and engagement (including inpatient, outpatient, and telehealth encounters or receipt of medication for opioid use disorder [OUD]), 12-week retention (days in treatment), and OUD pharmacotherapy retention. Telehealth treatment initiation and engagement were also examined. Differences in changes in utilization by age group, race, ethnicity, and socioeconomic status (SES) were examined.

Results

Among the 19 648 participants in the pre-COVID-19 cohort (58.5% male; mean [SD] age, 41.0 [17.5] years), 1.6% were American Indian or Alaska Native; 7.5%, Asian or Pacific Islander; 14.3%, Black; 20.8%, Latino or Hispanic; 53.4%, White; and 2.5%, unknown race. Among the 16 959 participants in the COVID-19 onset cohort (56.5% male; mean [SD] age, 38.9 [16.3] years), 1.6% were American Indian or Alaska Native; 7.4%, Asian or Pacific Islander; 14.6%, Black; 22.2%, Latino or Hispanic; 51.0%, White; and 3.2%, unknown race. Odds of overall treatment initiation increased from before the COVID-19 pandemic to COVID-19 onset for all age, race, ethnicity, and SES subgroups except for patients aged 50 years or older; patients aged 18 to 34 years had the greatest increases (adjusted odds ratio [aOR], 1.31; 95% CI, 1.22-1.40). Odds of telehealth treatment initiation increased for all patient subgroups without variation by race, ethnicity, or SES, although increases were greater for patients aged 18 to 34 years (aOR, 7.17; 95% CI, 6.24-8.24). Odds of overall treatment engagement increased (aOR, 1.13; 95% CI, 1.03-1.24) without variation by patient subgroups. Retention increased by 1.4 days (95% CI, 0.6-2.2 days), and OUD pharmacotherapy retention did not change (adjusted mean difference, -5.2 days; 95% CI, -12.7 to 2.4 days).

Conclusions

In this cohort study of insured adults with drug use problems, there were increases in overall and telehealth addiction treatment utilization after telehealth policies changed during the COVID-19 pandemic. There was no evidence that disparities were exacerbated, and younger adults may have particularly benefited from the transition to telehealth.

Fentanyl-driven acceleration of racial, gender and geographical disparities in drug overdose deaths in the United States

We examine trends in drug overdose deaths by race, gender, and geography in the United States during the period 2013-2020. Race and gender specific crude rates were extracted from the final National Vital Statistics System multiple cause-of-death mortality files for several jurisdictions and used to calculate the male-to-female ratios of crude rates between 2013 and 2020. We established 2013-2019 temporal trends for four major drug types: psychostimulants with addiction potential (T43.6, such as methamphetamines); heroin (T40.1); natural and semi-synthetic opioids (T40.2, such as those contained in prescription pain-killers); synthetic opioids (T40.4, such as fentanyl and its derivatives) through a quadratic regression and determined whether changes in the pandemic year 2020 were statistically significant. We also identified which race, gender and states were most impacted by drug overdose deaths. Nationwide, the year 2020 saw statistically significant increases in overdose deaths from all drug categories except heroin, surpassing predictions based on 2013-2019 trends. Crude rates for Black individuals of both genders surpassed those for White individuals for fentanyl and psychostimulants in 2018, creating a gap that widened through 2020. In some regions, mortality among White persons decreased while overdose deaths for Black persons kept rising. The largest 2020 mortality statistic is for Black males in the District of Columbia, with a record 134 overdose deaths per 100,000 due to fentanyl, 9.4 times more than the fatality rate among White males. Male overdose crude rates in 2020 remain larger than those of females for all drug categories except in Idaho, Utah and Arkansas where crude rates of overdose deaths by natural and semisynthetic opioids for females exceeded those of males. Drug prevention, mitigation and no-harm strategies should include racial, geographical and gender-specific efforts, to better identify and serve at-risk groups.

Substance Use and the Self-Management of Persistent Symptoms of COVID-19

Background: Understanding the self-management practices of persistent symptoms of SARS-Cov-2 (COVID-19) is critical given the misinformation that has been presented about this disease in the U.S. The purpose of this descriptive study is to assess the self-management of persistent symptoms of COVID-19 with commonly used and misused substances (i.e., alcohol, marijuana and commonly prescribed medications) among adults in the U.S. Methods: The data for this study comes from a cross-sectional survey of U.S. adults that was designed to broadly assess symptom burden, persistent symptom patterns, self-efficacy for symptom management and self-management strategies among people who experienced persistent/Long COVID. Multiple logistic regression analyses were used to assess how symptom length of COVID-19 was associated with the use of several substances to manage these persistent symptoms. Results: The analysis found that adults who had COVID-19 symptoms that persisted for 13 weeks or longer had higher rates of using alcohol (27.3%), marijuana (30.9%) and prescription tranquilizers (21.4%) to manage these symptoms when compared to their adult peers who had COVID-19 symptoms persist for only 4 weeks or less. For instance, the odds of indicating the use of marijuana (AOR = 4.21 95% CI = 1.68,10.5) to manage COVID-19 related symptoms was roughly four times higher for respondents who had COVID-19 symptoms persist for 13 weeks or longer when compared to respondents whose COVID-19 symptoms persisted for only 4 weeks or less. Conclusion: The findings suggest that screening of substance use disorders should be considered among healthcare providers who are treating adults who have persistent symptoms of COVID-19.

Characteristics of fatal drug overdoses among college age decedents in Tennessee, 2019-2020

Purpose

College age persons experienced unique disruptions to their regular lives during the COVID-19 pandemic, sometimes resulting in negative coping mechanisms. We examined changes in the number of and characteristics of college age fatal drug overdoses before and during the early COVID-19 pandemic.

Methods

We conducted a statewide cross-sectional study to determine the changes in the number and characteristics of college age fatal drug overdose decedents before and during the COVID-19 pandemic using 2019-2020 data from the Tennessee State Unintentional Drug Overdose Reporting System. We defined college age as 18-24 years. Frequencies and rates were generated to compare demographics, circumstances, and toxicology between 2019 and 2020.

Results

From 2019 to 2020, 336 college age persons experienced an unintentional or undetermined fatal drug overdose in Tennessee. Characteristics of college age decedents: mean age 21.7 years, 68.5% males, and 71.4% White. Rates of fatal overdoses among college age persons increased 50.0% overall, 150.1% for female decedents, and 141.7% for Black decedents. Fewer people were treated for substance use disorder or mental health conditions (p = 0.0243) in 2020.

Conclusion

This analysis can inform local and regional public health workers to implement focused prevention and intervention efforts to curtail the overdose epidemic among college age persons in Tennessee.

Major Depression in Postpartum Women during the COVID-19 Pandemic: Can Social Support Buffer Psychosocial Risks and Substance Use?

Rates of mood disorders and substance use increased during the COVID-19 pandemic for postpartum women. The present study's aims were to: (1) examine the prevalence of major depressive disorder (MDD) in postpartum women during the COVID-19 pandemic, and (2) evaluate whether social support can buffer the associations between MDD, psychosocial factors (perceived stress, generalized anxiety, and intimate partner violence) and substance use (alcohol and drug use). A nationwide survey included 593 postpartum mothers (within 12 months from birth). Participants were assessed for a provisional diagnosis of MDD, and provided responses on validated instruments measuring stress, intimate partner violence, suicidal ideation, generalized anxiety, social support, and substance use. A hierarchical logistic regression model assessed the association of psychosocial factors and substance use with MDD. The final model shows that social support attenuates the association of MDD with perceived stress, alcohol use, and drug use, but does not buffer the relationship of MDD with anxiety or intimate partner violence. Social support was shown to significantly attenuate the effects of stress, alcohol use, and drug use on MDD, suggesting that the presence of a strong, supportive social network should be an area of increased focus for public health and healthcare professionals when caring for postpartum women.

Trends in psychiatric diagnoses by COVID-19 infection and hospitalization among patients with and without recent clinical psychiatric diagnoses in New York city from March 2020 to August 2021

Determining emerging trends of clinical psychiatric diagnoses among patients infected with the SARS-CoV-2 virus is important to understand post-acute sequelae of SARS-CoV-2 infection or long COVID. However, published reports accounting for pre-COVID psychiatric diagnoses have usually relied on self-report rather than clinical diagnoses. Using electronic health records (EHRs) among 2,358,318 patients from the New York City (NYC) metropolitan region, this time series study examined changes in clinical psychiatric diagnoses between March 2020 and August 2021 with month as the unit of analysis. We compared trends in patients with and without recent pre-COVID clinical psychiatric diagnoses noted in the EHRs up to 3 years before the first COVID-19 test. Patients with recent clinical psychiatric diagnoses, as compared to those without, had more subsequent anxiety disorders, mood disorders, and psychosis throughout the study period. Substance use disorders were greater between March and August 2020 among patients without any recent clinical psychiatric diagnoses than those with. COVID-19 positive patients (both hospitalized and non-hospitalized) had greater post-COVID psychiatric diagnoses than COVID-19 negative patients. Among patients with recent clinical psychiatric diagnoses, psychiatric diagnoses have decreased since January 2021, regardless of COVID-19 infection/hospitalization. However, among patients without recent clinical psychiatric diagnoses, new anxiety disorders, mood disorders, and psychosis diagnoses increased between February and August 2021 among all patients (COVID-19 positive and negative). The greatest increases were anxiety disorders (378.7%) and mood disorders (269.0%) among COVID-19 positive non-hospitalized patients. New clinical psychosis diagnoses increased by 242.5% among COVID-19 negative patients. This study is the first to delineate the impact of COVID-19 on different clinical psychiatric diagnoses by pre-COVID psychiatric diagnoses and COVID-19 infections and hospitalizations across NYC, one of the hardest-hit US cities in the early pandemic. Our findings suggest the need for tailoring treatment and policies to meet the needs of individuals with pre-COVID psychiatric diagnoses.

Characteristics of events in which police responded to overdoses: an examination of incident reports in Rhode Island

Background

Narrow or non-existent Good Samaritan Law protections and harsh drug selling statutes in the USA have been shown to deter bystanders from seeking medical assistance for overdoses. Additionally, little is known about the actions that police take when responding to overdose events. The objectives of this study were to assess the prevalence and correlates of naloxone administration by police, as well as to examine overdose events where arrests were made and those in which the person who overdosed was described as combative.

Methods

We analyzed incident reports of police responding to an overdose between September 1, 2019, and August 31, 2020 (i.e., 6 months prior to and during the COVID-19 pandemic), from a city in Rhode Island. We examined characteristics of incidents, as well as individual characteristics of the person who overdosed. Correlates of police naloxone administration were assessed using Wilcoxon rank sum tests and Fisher’s exact tests, and we examined incidents where arrests occurred and incidents in which the person who overdosed was described as combative descriptively.

Results

Among the 211 incidents in which police responded to an overdose during the study period, we found that police administered naloxone in approximately 10% of incidents. In most incidents, police were the last group of first responders to arrive on scene (59%), and most often, naloxone was administered by others (65%). Police were significantly more likely to administer naloxone when they were the first professionals to arrive, when naloxone had not been administered by others, and when the overdose occurred in public or in a vehicle. Arrests at overdose events were rarely reported (1%), and people who overdosed were rarely (1%) documented in incident reports as being ‘combative.’

Conclusions

Considering these findings, ideally, all jurisdictions should have sufficient first responder staffing and resources to ensure a rapid response to overdose events, with police rarely or never dispatched to respond to overdoses. However, until this ideal can be achieved, any available responders should be dispatched concurrently, with police instructed to resume patrol once other professional responders arrive on scene; additionally, warrant searches of persons on scene should be prohibited.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12954-022-00698-2.

The overdose epidemic: a study protocol to determine whether people who use drugs can influence or shape public opinion via mass media

BACKGROUND

We are currently witnessing an ongoing drug overdose death epidemic in many nations linked to the distribution of illegally manufactured potent synthetic opioids. While many health policy makers and researchers have focused on the root causes and possible solutions to the current crisis, there has been little focus on the power of advocacy and community action by people who use drugs (PWUDs). Specifically, there has been no research on the role of PWUDs in engaging and influencing mass media opinion.

METHODS

By relying on one of the longest and largest peer-run drug user advocacy groups in the world, the Vancouver Area Network of Drug Users (VANDU), newspaper articles, television reports, and magazines that VANDU or its members have been directly involved in will be identified via two data bases (the Canadian Newsstream & Google News). The news articles and videos related to the health of PWUDs and issues affecting PWUDs from 1997 to the end of 2020 will be analyzed qualitatively using Nvivo software.

DISCUSSION

As our communities are entering another phase of the drug overdose epidemic, acknowledging and partnering with PWUDs could play an integral part in advancing the goals of harm reduction, treatment, and human rights.