A qualitative assessment of circumstances surrounding drug overdose deaths during early stages of the COVID-19 pandemic

SUDORS Data Brief, Number 2, August 2022

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Lauren J. Tanz, ScD; Amanda T. Dinwiddie, MPH; Stephanie Snodgrass, MPH; Julie O’Donnell, PhD; Christine L. Mattson, PhD; Nicole L. Davis, PhD

Introduction

There were 91,799 drug overdose deaths in the U.S. in 2020, a 30% increase from 2019, which began accelerating in March 2020. ^1,2 The COVID-19 pandemic was declared a national emergency on March 13, 2020 and during March 1–May 31, 2020, 42 states and territories issued mandatory stay-at-home orders.³  The pandemic and vital public health mitigation measures designed to reduce disease spread potentially led to unintended social and economic consequences (e.g., depression, health care disruption), which can increase overdose risk.^4,5 These consequences, combined with interruptions and changes in illicit drug supply,⁶ possibly contributed to increased fatal overdose risk for persons who use drugs (PWUD).⁷

Multiple reports indicate drug overdoses have increased during the COVID-19 pandemic.^1,2,8-12 In December 2020, the Centers for Disease Control and Prevention (CDC) issued a health advisory highlighting provisional data indicating a substantial increase in overdose deaths beginning in 2019 and accelerating in early 2020, and called for essential services to remain accessible for those at risk of overdose.²  However, data are limited on COVID-19 specific circumstances that may have contributed to the rise in overdose deaths, particularly leading up to and after implementation of mitigation strategies. We utilized free-text narratives from CDC’s State Unintentional Drug Overdose Reporting System (SUDORS) to understand how COVID-19 specific circumstances might have contributed to overdose deaths across the U.S. and inform prevention and response efforts for future emergencies.

Data Source and Methods

SUDORS captures information on unintentional and undetermined intent drug overdose deaths from 47 states and the District of Columbia. Jurisdictions abstract data from death certificates and medical examiner/coroner (ME/C) reports, including death scene investigations and postmortem toxicology, to capture decedent demographics, overdose-specific circumstances, and drugs involved (i.e., listed as cause of death). Additionally, abstractor-drafted case narratives provide context not captured through discrete fields. This activity was reviewed by CDC and was conducted consistent with applicable federal law and CDC policy.[a]

Analyses were restricted to 33 states that reported overdose deaths which occurred during January–June 2020. Abstractors documented evidence of COVID-19-related circumstances in case narratives. COVID-19-related circumstances were identified using narrative text searches for “COVID”, “coronavirus”, “corona “, “pandemic”, “quarantine”, and “social distanc”. Searches for “isolat”, “mask”, and misspellings were also performed, but did not identify any relevant narratives. Qualitative analyses were restricted to deaths with documented COVID-19-related circumstances. Two independent reviewers examined all cases with at least one COVID-19-related circumstance to develop and finalize a codebook of key themes. The reviewers determined which circumstances to include under each theme, and then re-examined all cases to apply these codes. After the second review, they resolved any discrepancies in applied codes by case. Following code application, themes were divided into two overarching categories and quotes were identified to provide representative examples of each theme.

Results

Among 20,957 overdose deaths reported by 33 jurisdictions during January 2020–June 2020, 563 met inclusion criteria for COVID-19 related circumstances; 96% of these 563 deaths occurred during March 15–June 30, 2020.

Two overarching COVID-19-related themes were identified: physical and mental impacts of the pandemic and missed touchpoints or opportunities for intervention (Figure 1). Mental health impacts, such as depression, anxiety, or stress about COVID-19, or resulting from mitigation measures, were commonly noted. For example, one decedent “told her boyfriend that she was very depressed over the recent COVID-19 pandemic and was afraid of relapsing due to the social isolation”. Narratives also noted decedents experienced job loss and financial strain, which potentially contributed to overdose deaths. One narrative described that the decedent “relapsed two months prior (to overdose death) due to job loss due to COVID”. The pandemic also resulted in altered living arrangements, including relocation to avoid exposure, staying with relatives, and experiencing housing instability or homelessness. Finally, some decedents had potential COVID-19 exposures, symptoms, and/or diagnosis leading up to or at the time of death.

Missed touchpoints or opportunities for intervention included limited bystander presence, substance use disorder(s) (SUD) treatment changes, other clinical-related changes, and criminal justice system release. Potential bystanders were sometimes unable to intervene and possibly prevent the fatal overdose because they were spatially separated (e.g., in a different room) or not present because of COVID-19 precautions. One narrative noted the decedent’s “wife and children had been staying out of state for the past week due to his (the decedent’s) potential risk of being exposed to COVID-19”. Examples of SUD treatment changes were delayed or denied treatment and transitions to virtual sessions. Other clinical-related changes included cancelled or postponed medical care due to COVID-19, or fear of seeking care during COVID-19. For example, one narrative stated that the decedent “had a broken clavicle that was supposed to be surgically fixed but had been postponed due to COVID-19. He was on several medications and is suspected to have taken more than prescribed to handle the pain.” Lastly, some decedents were released early from the criminal justice system because of COVID-19 and may not have had appropriate linkage to SUD care or treatment, or suitable housing.

Discussion

Qualitative analyses using free-text narratives in SUDORS identified missed touchpoints and opportunities for intervention, and pandemic-related factors potentially contributing to overdose deaths. To our knowledge, this is the first study to utilize qualitative data to identify COVID-19-related circumstances surrounding overdose deaths.

The acceleration of overdose deaths corresponded with implementation of the national stay-at-home order as part of the “15 Days to Slow the Spread” proclamation on March 16, 2020 and the rise in COVID-19 cases.^2,13 Results suggest pandemic mitigation measures yielded social isolation and mental health impacts, job loss and financial strain, and missed touchpoints and opportunities for intervention, which potentially contributed to some overdose deaths. Cancelled and postponed medical care due to COVID-19 fear, diagnosis, or medical facility precautions represent possible missed touchpoints between healthcare systems and persons with SUD. It is critical to expand SUD screening, maintain SUD treatment, and expand telehealth during emergencies to ensure persons are linked to available services.^2,14 Some decedents released early from the criminal justice system because of COVID-19 might not have been linked to SUD care or treatment upon release. Public health departments, harm reduction organizations, and providers should consider innovative solutions to ensure treatment access and care linkage for those released from institutional settings and initiate or continue medications for opioids use disorder among these persons.^2,14

Potential bystanders were often spatially separated from decedents due to COVID-19 precautions. Altered living arrangements could have resulted in living with persons unaware of their substance use or how to respond to an overdose, both of which limit overdose recognition and response. Prevention messaging should encourage PWUD to not use alone and ensure co-habitating friends and family check on PWUD and know how to recognize and respond to an overdose. Harm reduction and community organizations and providers play important roles in discussing overdose prevention with PWUD, and their family and friends, and providing naloxone to those likely to witness, experience, or respond to an overdose.^2,14

Findings indicate decedents experienced stressors associated with initiation or worsening of substance use.¹⁵ Other research noted persons initiated or increased substance use to cope with pandemic impacts, directly linking pandemic stressors to substance use.^16,17 Expanding SUD screening and treatment during emergencies might be essential to identify persons at increased risk and prevent overdose.^2,14

Analyses were limited to states with data available for deaths during January 2020–June 2020. Results might not be generalizable to the entire U.S.; however, inclusion of 33 states yields, to our knowledge, the most comprehensive qualitative assessment to date of circumstances surrounding overdose deaths during the pandemic. Second, our analysis depended on ME/C reports including COVID-19-related circumstances and identifying them in narratives through keywords. Thus, small sample size and lack of inclusion may not equate to lack of experienced COVID-19 related circumstances; some themes might not have been identified, possibly limiting generalizability. However, our analysis identified several important themes and narratives that illuminated them. Third, the analysis did not examine reasons unrelated to COVID-19 that may have resulted in increased overdose deaths in 2020. Lastly, COVID-19 cases peaked several times during 2020–2021;¹⁸ we only assessed overdose deaths during the first peak. Circumstances might have changed as the pandemic continued; however, our results can inform prevention and intervention opportunities related to overdose deaths during emergencies.

Although efforts were made to address SUD treatment barriers early in the COVID-19 pandemic,^19,20 addressing remaining missed touchpoints and intervention opportunities may help avoid surges in overdose deaths as the COVID-19 pandemic continues, and during future emergencies. This could include ensuring SUD treatment during reduced hours or closures, providing treatment opportunities for those experiencing mental health impacts, expanding naloxone availability in communities, and training potential bystanders to recognize and respond to an overdose. Continued surveillance and prevention efforts geared towards understanding and reducing impacts of pandemics and other emergencies on overdose deaths and including specific emergency preparedness plans to ensure continuation of prevention, care, and treatment for PWUD are essential to mitigate excess morbidity and mortality.

[a] See e.g., 45 C.F.R. part 46.102(l)(2), 21 C.F.R. part 56; 42 U.S.C. §241(d);  5 U.S.C. §552a; 44 U.S.C. §3501 et seq.

Definitions and Technical Notes

SUDORS: CDC’s State Unintentional Drug Overdose Reporting System (SUDORS) [PDF] collects information on drug overdose deaths of unintentional or undetermined intent. In 2016, SUDORS was launched as part of the Enhanced State Opioid Overdose Surveillance (ESOOS) program, which funded 12 states and in 2017, an additional 20 states and the District of Columbia (DC) were funded to abstract data on opioid-involved overdose deaths. In 2019, as part of CDC’s Overdose Data to Action (OD2A) program, SUDORS was expanded to collect data on all drug overdose deaths from 47 states and DC (collectively referred to as jurisdictions).

About the Authors

Lauren Tanz, Amanda Dinwiddie, Julie O’Donnell, Christine Mattson, and Nicole Davis work on the Overdose Mortality Team in the Epidemiology and Surveillance Branch in the Division of Overdose Prevention (DOP) at the National Center for Injury Prevention and Control. Stephanie Snodgrass works for Strategic Innovation Solutions, LLC (SIS) and is assigned to provide data management and statistical support to DOP.

Suggested Citation

Tanz LJ, Dinwiddie AT, Snodgrass S, O’Donnell J, Mattson CL, Davis NL. A qualitative assessment of circumstances surrounding drug overdose deaths during the early stages of the COVID-19 pandemic. SUDORS Data Brief, No 2. Atlanta, GA: Centers for Disease Control and Prevention, U.S. Department of Health and Human Services; 2022.

Acknowledgements

Jurisdictions participating in the State Unintentional Drug Overdose Reporting System and participating state or jurisdictional agencies, including health departments, vital registrar offices, and coroners and medical examiners offices.

Figure 1. COVID-19-related themes and supporting evidence identified from SUDORS case narratives — 33 states,^a January 2020–June 2020