While the United States has spent the last two years dealing with a pandemic that has killed more than a million Americans, the drug overdose crisis has also continued at an unprecedented pace. The latest estimates released by the Centers for Disease Control and Prevention show that more than 107,000 people died from overdoses in 2021, about a 15 percent increase from the prior year, in which 93,000 people died.
The first two years of the COVID-19 pandemic represent a dramatic increase in overdose deaths. Each death is a tragedy and leaves a void in our communities. Yet the question remains: Why have overdose deaths gone up so much during the pandemic, and what can policymakers do about it? This question has sparked fierce debate about whether measures to contain the pandemic have caused greater harm than the pandemic itself, and speculation that greater isolation led to greater drug use and therefore higher overdose deaths. As substance use researchers, we know that the causes of overdose deaths are more complex than increased physical isolation.
We conducted research investigating drug use patterns in Rhode Island, looking at state data for overdose mortality and interviewing people who use drugs. In one study that compared the first eight months of 2020 with the first eight months of 2019, we examined who was dying from overdose. We found that overdose deaths among men, those who had a prior mental health diagnosis, and those who had experienced job loss increased in 2020 compared with the previous year. Overdose deaths involving synthetic opioids like fentanyl and those that occurred in personal residences also increased from the previous year.
We also conducted qualitative interviews from late 2020 to summer 2021 with unstably housed people who use drugs, asking them how they navigated protecting themselves from COVID. Much like the general population, some were concerned about the virus and others were not. In the latter group, some referenced COVID risk as a secondary concern to that of overdosing. Regardless of personal fear, most people we spoke with experienced service interruptions and barriers to supports due to the virus. Easy access to harm reduction and other social services was disrupted, and access to protective measures like COVID testing was difficult — which was especially troublesome, since the latter was required for housing and treatment. All the while, being unhoused presented people with scenarios in which they were at elevated risk for contracting COVID and were left with few options to mitigate the risk.
What about the amount of drug use itself? CDC data suggest that some people began using drugs during the pandemic to cope with the stresses associated with it. However, overdose risk is more than just about the amount of drugs consumed — even small amounts can be toxic. Researchers recently found that while teenage drug use has stayed constant, teenage drug overdoses have skyrocketed. What this points to is an increasingly toxic supply of drugs — first adulterated with fentanyl, and now increasingly being modified with chemicals like the animal tranquilizer xylazine. People who use drugs must contend with a supply that is rapidly changing and increasingly dangerous.
What the evidence shows is that the pandemic did indeed make the overdose crisis worse, but in specific ways — through disruption of services, job loss, increased stress and mental health issues, and of course, through a changing and more toxic drug supply. These all have policy solutions that states can pursue. For instance, one study found that the harmful impacts job loss has on opioid overdose mortality decreases as the amount of state unemployment benefit levels increases, suggesting that the link between job loss and overdoses can be mitigated by providing financial assistance. Access to harm reduction services, such as safer-use supplies and supervised consumption sites should also be expanded, but some of these services are under attack in Congress and across the country. To address the toxic supply of drugs while long-term questions of legalization and regulation are debated, providing a safe supply of medical-grade stimulants and opioids like hydromorphone has been proposed as an alternative that has worked in the past. This can be through a variety of models including prescriptions and compassion clubs, for instance.
The way the pandemic’s impact on the overdose crisis is talked about often minimizes the harms that COVID causes and mentions a return to a pre-pandemic normal. It has been more than two years since the initial lockdowns of 2020; society is back open, and yet overdoses continue to be at an all-time high. Sticking to simplistic explanations that rationalize increased overdoses as a product of isolation alone obscures the specific reasons behind why such a spike may have occurred and, as a result, scuttles discussions of potential solutions outside of ending pandemic measures.
The pre-pandemic normal failed to provide people who use drugs with the support they need. Rather than returning to it, states need to reenvision it.
Abdullah Shihipar directs Narrative Projects and Policy Impact Initiatives at the People, Place & Health Collective at the Brown University School of Public Health. Alexandria Macmadu is a presidential postdoctoral fellow at Brown University. Alexandra Collins is an assistant professor of epidemiology at Brown University.