Estimating the uncertain effect of the COVID pandemic on drug overdoses

PLOS ONE RESEARCH ARTICLE Estimating the uncertain effect of the COVID pandemic on drug overdoses Ali Moghtaderi ID1*, Mark S. Zocchi2, Jesse M. Pines3,5, Arvind Venkat3,5, Bernard Black4,6 1 Milken Institute School of Public Health, George Washington University, Washington, DC, United States of America, 2 Heller School for Social Policy and Management, Brandeis University, Waltham, Massachusetts, United States of America, 3 US Acute Care Solutions, Canton, Ohio, United States of America, 4 Pritzker School of Law, Northwestern University, Evanston, Illinois, United States of America, 5 Department of Emergency Medicine, Allegheny Health Network, Pittsburgh, Pennsylvania, United States of America, 6 Kellogg School of Management, Northwestern University, Evanston, Illinois, United States of America a1111111111 a1111111111 a1111111111 a1111111111 a1111111111 * Abstract Objective OPEN ACCESS Citation: Moghtaderi A, Zocchi MS, Pines JM, Venkat A, Black B (2023) Estimating the uncertain effect of the COVID pandemic on drug overdoses. PLoS ONE 18(8): e0281227. https://doi.org/ 10.1371/journal.pone.0281227 Editor: Vincenzo Alfano, University of Naples Parthenope: Universita degli Studi di Napoli Parthenope, ITALY U.S. drug-related overdose deaths and Emergency Department (ED) visits rose in 2020 and again in 2021. Many academic studies and the news media attributed this rise primarily to increased drug use resulting from the societal disruptions related to the coronavirus (COVID-19) pandemic. A competing explanation is that higher overdose deaths and ED visits may have reflected a continuation of pre-pandemic trends in synthetic-opioid deaths, which began to rise in mid-2019. We assess the evidence on whether increases in overdose deaths and ED visits are likely to be related primarily to the COVID-19 pandemic, increased synthetic-opioid use, or some of both. Received: January 17, 2023 Accepted: July 16, 2023 Methods Published: August 10, 2023 We use national data from the Centers for Disease Control and Prevention (CDC) on rolling 12-month drug-related deaths (2015–2021); CDC data on monthly ED visits (2019-September 2020) for EDs in 42 states; and ED visit data for 181 EDs in 24 states staffed by a national ED physician staffing group (January 2016-June 2022). We study drug overdose deaths per 100,000 persons during the pandemic period, and ED visits for drug overdoses, in both cases compared to predicted levels based on pre-pandemic trends. Peer Review History: PLOS recognizes the benefits of transparency in the peer review process; therefore, we enable the publication of all of the content of peer review and author responses alongside final, published articles. The editorial history of this article is available here: https://doi.org/10.1371/journal.pone.0281227 Copyright: © 2023 Moghtaderi et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited. Data Availability Statement: All the data on overdose deaths were uploaded as part of the resubmission package. The national CDC non-fatal overdoses database was also uploaded. The Results Mortality. National overdose mortality increased from 21/100,000 in 2019 to 26/100,000 in 2020 and 30/100,000 in 2021. The rise in mortality began in mid-to-late half of 2019, and the 2020 increase is well-predicted by models that extrapolate pre-pandemic trends for rolling 12-month mortality to the pandemic period. Placebo analyses (which assume the pandemic started earlier or later than March 2020) do not provide evidence for a change in trend in or soon after March 2020. State-level analyses of actual mortality, relative to mortality predicted based on pre-pandemic trends, show no consistent pattern. The state-level results PLOS ONE | https://doi.org/10.1371/journal.pone.0281227 August 10, 2023 1 / 16 PLOS ONE COVID-19 pandemic and drug-related overdose and emergency department visits emergency department visit from the national staffing group belongs to the U.S. Acute Care Solutions and will remain confidential. The data use agreement in place. Individuals can reach Pablo Colden () in U.S. Acute Care Solutions for reasonable data requests. support state heterogeneity in overdose mortality trends, and do not support the pandemic being a major driver of overdose mortality. ED visits. ED overdose visits rose during our sample period, reflecting a worsening opioid epidemic, but rose at similar rates during the pre-pandemic and pandemic periods. Funding: The authors received no specific funding for this work. Conclusion Competing interests: The authors have declared that no competing interests exist. The reasons for rising overdose mortality in 2020 and 2021 cannot be definitely determined. We lack a control group and thus cannot assess causation. However, the observed increases can be largely explained by a continuation of pre-pandemic trends toward rising synthetic-opioid deaths, principally fentanyl, that began in mid-to-late 2019. We do not find evidence supporting the pandemic as a major driver of rising mortality. Policymakers need to directly address the synthetic opioid epidemic, and not expect a respite as the pandemic recedes. Introduction U.S. drug-related overdose deaths rose sharply from 71,000 in 2019 to 93,000 in 2020, and to 107,000 in 2021 [1]. Multiple studies have linked the onset of the COVID-19 pandemic in March 2020 to rising overdose deaths [2–7], and rising drug-related emergency department (ED) visits [8–12]. While some of these studies cite greater access to synthetic opioids as a secondary contributor [5, 6], they ascribe rising mortality and drug-related ED visits primarily to the pandemic and its related lockdowns, job loss, and social isolation [13]. News stories presented a similar narrative [14–16]. However, two Illinois studies report evidence for rising opioid-related deaths beginning in late 2019, suggesting an important role for non-pandemic factors [17, 18]. In addition, we previously found no increase in ED visits across 18 U.S. states for substance abuse during the early pandemic period from March-July, 2020 [19]. We revisit the evidence on the reasons for rising overdose mortality during the pandemic period by studying a longer time period, explicitly modeling the counterfactual of what levels of overdose mortality and ED visits would have been expected based on pre-pandemic trends, and examining both national and state trends. We examine two competing hypotheses. The first is that the pandemic may have been a principal driver of higher overdose deaths. This hypothesis predicts a rise in both overdose deaths and overdose-related ED visits, beginning in March 2020 (pandemic onset). Second, rising mortality might primarily reflect greater availability of synthetic opioids. This hypothesis would predict (...truncated)